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0 <br />STATE OF CALIFORNIA <br />0 <br />WATER RESOURCES CONTROL BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br />SiT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT l/ 5 CHANGE OF INFORMATION ❑ 7 <br />ONE ITEM © 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />[FACILITY/SITE NAMErR DDRESS INFORMATION <br />CARE OF A <br />CITY NAME <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PWCESSOR ✓ Box ii INDIAN <br />RESERVAT❑ 1 GAS STATION E:]3 FARM DTHEH TRUST LANDS or ❑ <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />OA NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />S yep yl 15V, <br />NIGHTS, NAME (LAT, FIRST) PH NE # WiTH AREA CODE <br />II. PROPERTY OWNER INFORMATION & DDRESS - <br />NAME p e, I, + Poc g <br />-�& <br />MAILING or STREET ADDRESS <br />CITY NAME <br />III. TANK OWNER INFORMATION & ADDRESS - <br />NAME <br />MAILING or STREET ADDRESS <br />CITY NAME <br />SITE <br />NEAREST CROSS STREET✓ Box to indicate ❑ PARTNERSHIP [ISTATE-AGEND <br />///��� <br />y / f ❑ CORPORATION ❑ LOCAL -AGENCY El <br />13 r u, <br />Ti j L ❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />STATE ZIP CODE S E PHONE #, WITH AREA CODE <br />CA 2.53 0cf3Y� <br />EPA ID # # 01 TANK's <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS, NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA. CODE <br />ST BE COMPLETED <br />CARE OF ADDRESS INFORMATION <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />STATE I ZIP CODE I PHONE #, WITH AREA CODE <br />COMPLETED) <br />OF ADDRESS INFORMATION <br />✓ Box lo' dicale El PARTNERSHIP Cl STATE -AGENCY <br />❑ COR <br />PO ION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />STATE 1 2T CODE I 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: 1.0 11. ❑ 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) <br />LOCAL AGENCY USE ONLY <br />DATE <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br />I Lf 1:3:2 <br /># of TANKS at SITE <br />F I I F(7)) <br />CURRENT LOCAL AGENCY FACILITY 10 # <br />APPROVED BY NAME <br />PHONE #WITH AREA CODE <br />PERMIT NUMBERT PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE <br />LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br />r YES ❑ NO ❑ rI <br />CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST <br />OR MORE TANK PERMIT FORM `B' APPLICATION(S), U�S THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />\ FORM A (3-2�86)� <br />DATA PROCESSING COPY <br />