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. ' <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A'. <br /> UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ER""NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE LY CLOSED SITE �{ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a f 4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> W <br /> FACILITYY SITE NAME CARE OF ADDRESS INFORMATION wW <br /> ADDRESS NEAREST CROSS STREET ✓Box toodicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> j Cl INDNIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA ` 1 A <br /> TYPE OFSINESS: ❑ 2 DISTRIBUTOR ❑ d P EMS 1/30x it INDIAN EPA ID # <br /> RESERVATION or /'�, #of TANK't <br /> 1 GAS STAT60N ❑ 3 FARM HER TRUST LANDS ❑ 'f AT THIS SITE 3 <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) PHONf N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNS INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADD SS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl 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. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> 5 <br /> EK <br /> JURISDICTION# Af3ENCY# FACILITY ID# #of TANKS at SITE <br /> 10101 / 1310 [010j��E] <br /> AGENCY FACILITY ID k APPROVE BY NAME PHONE#WITH AREA CODE <br /> PERMIT P OVAL AT PERMIT EXPIRATION DA <br /> r O a 3 I �l'D <br /> CENSUS TRA/CT# SUPE VISOR-DISTRICT CODE BUSINESS P N FILE DATE FILED <br /> 40 <br /> lC� C/ YES NOPERMIT AMOUNT SURCHARGE AMOUNT F£E CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESSIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 6 <br />