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STATE OF CALIFORNIA WATER RESOURCES CONTROBOARD <br /> ISE" A' <br /> Y: <br /> i <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Ln <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I <br /> ADDRESS NEAREST CROSS STREET ✓B,,1.irks, ❑ PARTNERSHIP Cl STATE AGENCY <br /> I C ,,. I� P�IPORANON 13LOCAL-AGENCY ❑ FEDERALAGENCY <br /> r�" aD� rS/`�' B—IADNIDUAL ❑ CDUNIY AGENCY <br /> CITY NAME Q j_,, � STATE ZIP CODE SITE PHONE II,WITH AREA CODE <br /> S+U-k h Y1 CA U rel_ Lo 9 33 q c7�r�< <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION orIf of TANK'# <br /> ❑ 1 GASSTATION ❑ 3 FARM ✓�5 OTHER TRUST LANDS ❑ -- AT THIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> U N). <br /> NIGHTS: NAME(IAST,FIRST) PHONE AT WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: I. II. 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 M JURISDICTION IT AGENCY# FACILITY ID R N of TANKS at SITE <br /> 10 10 1 2z 10101011 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> —3- m t5 -2-;( <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION OCODE CENS�4STjiACT# SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE/F�ILED�\ 4 5 <br /> -!]ST <br /> Iq2— YES NO ❑ _0 W (il. cO i <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> ITHIS 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 /> W FORMA(3-2-M) <br /> DATA PROCESSING COPY <br />