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moo, <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A'N - , <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> til <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> FMARK,ONLY ❑ I NEW PERMIT F-13 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITETEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE61 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) v <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> rs G( <br /> ADDRESS NEAREST CROSS STREET ✓BoxlolMicale C PARTNERSHIP C STATE AGENCY <br /> iv. ao�U,�J^ ❑ CORPORATION C LOCAL C FEDERAL AGENCY <br /> ❑ <br /> /Cn SS /J INDIVIDUAL ❑ CGUNYAGENCY <br /> CITY NAME STATEZIP CODE SITE PHONE a,WITH AREA CODE <br /> CA 53 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID a <br /> RESERVATION or A of TANSY <br /> ❑ 1 GAS STATION FARM ❑ SOTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> N A) 2dg <br /> N GH NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET A!lf0RESS ✓Be.to intlicate C PARTNERSHIP C STATE-AGENCY <br /> CCORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> 120Boy 1-1 INDIVIDUAL C COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL N TIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 9 it. ❑ Ill. ❑ <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 R AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA ODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Lill, <br /> � LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> v\ 3 2 '3,2YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Elf. <br /> ;-�— <br /> l :_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST,§R MORE TANK PERMIT FORM `B'APPLICATION(S), LIN SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> J FORM A(3-2-88) <br /> J DATA PROCESSING COPY <br />