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STATE OF CALIFORNIA WATER RESOURCES CONTROLBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM / ! µo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT F-13 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION RT-7­PEHMANENTLY CLOSED SITE FA' <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> W <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> A <br /> FACILITY/SITENAME ACAREOFADDRE INFORMATION <br /> LL( r �4Ze � nC_ MCLi 0, <br /> ADDRESS NEAREST CROSS STREET ✓Bm to mi 0 PAATNERSHT 0 STATEAGMD <br /> WORA71ON 0 LOCAL-Ci 0 FEDERAL AGENCY <br /> ❑ INDMDUAL 0 COUNIVAGENCY <br /> CITY NAMEn Lt c__^ STATCA '-I ( ID 3 SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS:/ OC <br /> p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IID # (_pl Af Of TANKK''N <br /> ❑ 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRUSTYAT LANDS ar ❑ THIS SITE <br /> 00 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(I-AST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 1 CARE OF ADDRESS INFORMATION <br /> in[ r/•�1,_ <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> Cl INDIVIDUAL ❑ COUNTYAGENCY <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 STREET ADDRESS ✓Box ti inNicale 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION Cl 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. it. ❑ 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 K AGENCY R FACILITY ID# If of TANKS at SITE <br /> DO oo <br /> CURRENT LOCAL AGENCY FACILITY IDN AQPROVED BY NAME' Ll PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COD CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G <br /> HatYES NO � —10 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Ill BY: / <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. C <br /> DATA PROCESSING COPY t � <br />