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STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UP bEFIGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE fell <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE tV <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q) <br /> O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> of <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G),6 s/a rY <br /> ADDRESS` I <br /> NEAREST CROSS STREET ✓Bmmirdale 0 PARTNERSHIP 0 STATE ASENCY <br /> 9,�2- e/ <A-, S - ❑ CORPORATION 0 LOCAL-AGENCf E3rEODPL-AGPILY <br /> ❑ IrvOMWAL 0 COUNTY AGENCY CITU NAME _ STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> iT c�oro <br /> CA 7/--;JY <br /> TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑ /PROCESSOR ✓Box B INDIAN EPA ID N <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER r 0 of TANK's TRUST LANDS ATION o ❑ AT THIS S1TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS, NAME(LAST,FIRST) PHONE N 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 AOORESS ✓Box to irld..te ❑ PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to md'Fate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ I. ❑ 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# IFACILITY ID N N of TANKS at SITE <br /> cJ ❑� 1, C -/ L) / y L: <br /> \ CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER 4P6RM1TROVALDATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT NUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE FILEDYES NO ❑ /c -,�J -`J 0CHECKR PERMIT AMOUNTURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> �U <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASOp MORE TANK PERMIT FORM 'B'APPLICATION(S), I!yL�SS THIS IS A CHANGE OF SITE INFORMATION ONE' <br /> FORMA(3�2-AB) . <br /> DATA PROCESSING COPY <br />