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STATE OF CALIFORNORO ,. <br /> WATER RESOURCES CONT BOARD <br /> Na <br /> FORM 'A': _" <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION r1 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ao <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY'/SITE ME ✓ / , y CARE OFADDRESS INFORMATION <br /> 1 U I N <br /> ADDRESSNEAREST CROSS STREET ✓Si to inloi Ll PARTNERSHIP El STATE AGENCY <br /> Cl <br /> ❑ CORPORATION 1:1 LOCAL AGENCY ElFEDERA A NCY <br /> ❑ :NOImouAL ❑ caurvn Acervcr <br /> CITY NAME' STATE ZIP CODE SITE RHO NE#,WITH AREA CODE <br /> `J CA 2-05'_ <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'# <br /> ❑ 1 GAS STATION [:] 3 FARM �5 OTHER TRUST LANDS RESERVATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME( ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> —r\ 1 , '(�G —'I -,T4 9' <br /> NIGHTS'. NAME(LAST FIRST) v <br /> .M PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEe11r�� <br /> CARE OF ADDRESS INFORMATION <br /> rl� � <br /> MAILINGo REET DERE ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> �j ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> Q ❑ INDIVIDUAL ❑ COUNTY-AGENCY L <br /> CITY NAME STATE ZIP CODE I PHONE#,WITH AREA CODE <br /> s -20 9-tlob-311 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME I I J CARE OF ADDRESS INFORMATION <br /> MAILING or STF ADD SS 1 ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDER -AGENCY <br /> �a ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#,WITH AREA rOOE <br /> G <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: I. ❑ 11.10 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID If #OI TANKS at SITE <br /> [S 1010111Z 101110 1 / <br /> CURRENT LOCAL AGEN�ACILTV ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER `t PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVIS R-QISTRI T CODE BUSINESS PLAN FILED DATE FILED <br /> v'�1 I YES 0 Nci <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> RM A(3-2-88) S <br /> DATA PROCESSING COPY <br />