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STATE OF CALIFORS WATER RESOURCES CONTROL BOARD <br /> FORM 'A': I <br /> UNDERGROUND STORAGE TANK PROGRAM = " %o <br /> SITE C� FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION ' �, o <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE ^r,.oe " <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ENTLY CLOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) Cb <br /> CTI <br /> FACILITY/SITE NAME ' (✓ CARE OF ADDRESS INFORMATION <br /> CA O <br /> ADDRESS Q /n��/^y / NEAREST CROSS STREqm <br /> PAWNESGNIP 0 STATE-AGENCY <br /> '3 f• 11A �) �, l) LOGL.AGENGY 0 FEDERAL AGENCY <br /> Y LZ AGENCY <br /> CITY NAME STATE ZIN 0,WI H ARE CODE <br /> CA �-'�G�� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 9 FARM ❑ 5 OTHER RESETRUST LANDS TION m ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUMY-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 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# III JURISDICTION N AGENCY k FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FA IL TY ID N APPROVED BY NAME I PHONE N WITH AREA CODE <br /> U Al It? 37 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE e <br /> LOCATION CODE CENSUS TRACTT## ''-lE SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> /)3 Z D V 3 L YES NO U.2 <br /> Kw <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BTS-"aaaaaaa /� <br /> Nv oj <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PoTlgceclntn nnoo <br />