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STATE OF CALIFORNIA WATER RESOURCES CONTRO@lOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION $ ° / 10 <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT M3 RENEWAL PERMIT HANGE OF INFORMATION Y CL DSI fJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CTI <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Y <br /> ADDRESS NEAREST CROSS STREET ✓Bos N M.W ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 3 ' ❑ CORPORATION ClIOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE S TE PHONE p,WITH ARE ODE <br /> C CA aoZ o a0 (o d ,; <br /> TYPE OF BUSINESS'. ❑2 DIS UTO ❑ 4 PROCESSOfl ✓Box it INDIAN EPA to N <br /> I ol7 <br /> [__jI GAS STATION 3 FARM E] 5 OTHER RESERVATION or ❑ � S SITE AT THIS STE <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 /> - i ao 3�8- a <br /> I NIGHTS: NAME(LAST,FAIR ^) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> { 's ` rte <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREtr ADDRESS ✓Box loiHoicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> I ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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 STRE&ADDRESS ✓Box to,mcwe ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. P, 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION N AGENCY N FACILITY 10 N N of TANKS a1 SITE <br /> �4 l 3 6 a () 3 <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACT N Su [STRICT CODE BUSINESS PLAN FILED DATE FIL61 ED <br /> a YES ❑ NO <br /> CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM I I B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3.2.88) <br /> DATA PROCESSING COPi • <br />