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s <br /> STATE OF CALIFORNIK WATER RESOURCES CONTROBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EAC 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 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bor.to irAinR ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 62Cn ❑ WPPOAATION ❑ LOCAL AGENCY ❑ FEDERAL�1K111 ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> i-IiiCA 6.2 <br /> .36 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR I/Box if INDIAN EPA ID # _ #of TANK's <br /> RESER <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS of ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST, <br /> NIGHTS'. NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAS �\ \ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMI <br /> NAME CARE OF ADDRESS If v' <br /> MAILING or STREET ADDRESS ✓Dox to Indicate �y ' - <br /> ❑ CORPORATIC <br /> ❑ INDIVIDUAL <br /> CITY NAME STATE <br /> SCJ <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLET <br /> NAM CARE OF ADDRESS IN <br /> MAILING or STREET ADDRESS ✓Box to lodicate ` <br /> ❑ CORPORATIO �d <br /> Cl INDIVIDUAL <br /> CITY NAME STATE <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. ❑ 111.❑ <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# JURISDICTION a AGENAGENCYCY# FACILITY ID# #of TANKS at SITE <br /> O0 5' z1 C)10 2 <br /> CURRENT <br /> nLOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> K <br /> PERMIT NUMBER PERMIT APPROVLDATE PERMIT EXPIRATION DATE <br /> LOCATION CODE C;N,S,US?R'CT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 1. L J YES E] NOCHE PERMIT AMOUNT SURFEE 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 /> ,V,N1 FORM A(3-2-88) \ ' <br /> DATA PROCESSING COPY U\ <br />