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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> qf��. 1M1 <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM W �" <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 CHANGE OF INFORMATION VP11MANENTLY ANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSUREz <br /> II. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED)FACILITY/SIT NAMECARE OF ADDRESS INFORMATION ,ADDRESS NEAREST CROSS STREET ✓Bw lo ❑ STAME-AGENLY �❑ COIN -FGENp O FEDERAL AGENCY❑ INDMW AGENCYCITY NAME _ STATE ZIP CODE ,WITH AREA CODECA - �TYPE OF BUSINESS: 2 DISTRIBUTO ❑ 4 PROC ✓Box if INDIAN EPA ID1 GAS STATION ❑3 FARM THER TRUSTYLANDS ATION or ❑ THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (yam - G SSD i - XJ <br /> NIGHTS: NAME(LAST,PIKS ) PHONE#WITH AREA CODE NIGHTS: NAMlSUAST,FIRS­Fr PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDR 5 V Box to indicate ❑� PARJJyAIIEEgqS5HIP 0 STATE-AGENCY <br /> 0 CORPORATION IO�tOC;AL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME �- STATE ZIP CODE P NE#, ITH AREA CODE <br /> S37 <br /> III. TANK OWNER IN96RMATION & ADDRESS - (MUST BE COMPLETED) <br /> Ir NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU 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: 1. ❑ If. 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# JURISDICTION At AGENCY# FACILITY ID# #DI TANKS at SITE <br /> CURRENT LOCAL CY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> (�3 YES NO ❑ <br /> CHECK# PERMITAMOUN SURCHAR EAMOU T FEE CODE RECEIPT# gy rO� <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 /> FORMA(3-2-80) All <br /> DATA PROCESSING COPY < <0"1q <br />