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STATE OF CALIFORNIf WATER RESOURCES CONTROL OARD 5. r <br /> S M1f <br /> W A <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " * <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY EY/l NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1'+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> G7 <br /> FACILINAME CARE OF ADDRESS INFORMATION <br /> w <br /> ADDRESSO f NEAREST CROSS STREET ✓BOID vdiure Ill PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL 0 FEDERAL AGENCY <br /> ❑ INDIVIDUAL 0 COUNn_AGENCY <br /> CITY NAME jol STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4>@CESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or {7 ��� Nof TANK'a <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ a I/� r`�i AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST( PHONE N WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE IX WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERALAGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ I. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> m = = 101oll7a ,SD l <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVE BY NAAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER <br /> U© I J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSSTRACT N SUP VISOR-DISTRICT CODE BUSINESS PLAN FILE DATE FILED <br /> p?3, 9,0 a YES ❑ NO <br /> CHEC N 1 PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ^ <br /> FORM A(3-2-88) S I <br /> DATA PROCESSING COPY <br />