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STATE OF CALIFORA <br /> WATER RESOURCES CONTRIL BOARD <br /> FORM `A': <br /> •WP c eK��\,\ <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> OACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE 13' <br /> ,C\..IFO <br /> =MARKONLY ❑ ) NEW PERMIT ❑3 RENEWAL PERMIT❑ ❑ q AMENDED PERMIT 5 CHANGE OF INFORMATION ❑ 7 pERMANE �SEDSITE� <br /> 2 INTERIM PERMIT <br /> ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME j <br /> �!,{pILA /L , 7!� CARE OF ADDRESS INFORMATION <br /> ADDRESS 7 VWNl� <br /> •�� �(� r ��� � � NEAREST CROSS STREET ✓Box loindicale ❑ PARTNERSHIP <br /> 0 STATE-AGENCY <br /> Q <br /> CITY NAME ❑ CORPORATION ElLOCAL-AGENCYFEDERAL AGENCY <br /> ❑ INDIVIDUAL 11COUNTY-AGENCY <br /> ZIP <br /> / STATE COD <br /> l E SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTORCA <br /> ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER RESERVATION or ❑ If of TANK's <br /> TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY El STATE-AGENCY <br /> CITY NAME ❑ INDIVIDUAL LJCOUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> [AM <br /> CARE OF ADDRESS INFORMATION <br /> or STREET ADDRESS <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 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: I. ❑ II. ❑ 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) <br /> 7 <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID If #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# O <br /> 'p �r { APPROVED BY NAME PHONE#WITH AREA CODE <br /> ri%g— 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> S(� Z DATE FILED <br /> CHECK# J / YES ❑ NO ❑ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE /� <br /> RECEIPT# BY: <br /> G,Iev <br /> THIS FORM MUST BE ACCOMPANIED BY AT 1.61)OR MORE TANK PERMIT FORM `B'APPLICATIONS LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br /> ' FORMA 3-2-88) <br /> ' J ✓� DATA PROCESSING COPY <br />