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STATE OF CALIFORA WATER RESOURCES CONT BOARD <br /> J. s <br /> { r �v i <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -�. ; <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE I-a <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> FA <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> Ln <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> � <br /> ACI FIL UDS <br /> ADDRESS NEAREST CROSS STREET ✓Ba to iwliale ❑ PARTNERSHIP Cl STATE AGENCY <br /> Mf ❑ CORPORATION [ILOCALAGENCY 13FEDERAL AGENCY <br /> ❑ INDIVIDUAL Cl COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. 2 DISTRIBUTOR [:] 4 P TRUST LANDS <br /> OCESSOR I/Box if INDIAN EPA ID N #of TANK'e <br /> I GASSTATION ❑ 3 FARM 5 OTHER RESERVATION or ❑ AT THIS SITE Z <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ��5 -�i s --Foe ii <br /> NIGHTS: NAME(LAST,FI T) PHONE p 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 ADDRESS ✓Box lointlicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING/_or STREET ADDRESS ✓Box to indicate LI PARTNERSHIP ❑ STATEAGENCY <br /> S� 11 CORPORATION ElLOCAL-AGENCY 11FEDERAL-AGENCY• CQL/ [I INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFI ATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. '] 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 Is AGENCY41 FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID Nq. APPROVED BY NAME PHONE N WITH AREA CODE <br /> /LI/L�// /� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESSPUN FILED NO ❑ �E 10 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# S <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 0 <br />