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STATE OF CALIFORN WATER <br /> r� <br /> RESOURCES CONTROL BOARD <5`�t....w.w;N ..r"�, <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `Ak"oP <br /> MARK ONLY ❑ I NEW PERMIT 1:13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE " 41 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) mow; <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION [ <br /> ADDRESS NEAR T CROSS STREET ✓Bozto inAicale ❑ PARTNERSHIP 1:1 STATE-AGENCY <br /> DLi cA ai' n )n n ❑ CO TION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> l 41C.1� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME „^ STATE Z CODE SITE PHONE#,WITH AREA CODE <br /> 1( � \j f_ cA3.3 X31 SN <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM THER RESERVATION or ❑ #of TANK's <br /> TRUSTILANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER 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#,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 1 <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. V 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 If AGENCY# FACILITY ID If #of TANKS at SITE <br /> I I LO 10 GI 1 aD I oo <br /> CURRENT LOCAL AGENCY FACILITY ID# � APPROVED BY NAME PHONE#WITH AREA CODE <br /> , 14 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE JFEECODE <br /> RMITEEXPIRATION DATE <br /> LOCATION CO CENSUS TRACT SUPERVISOR-DI�I�CODESINEN❑FILED ❑ DATE FILED <br /> jl\}`t`I� NO . <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT RECEIPT# 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 INFORMATI N <br /> FORMA(3-2-88) 0 ONLY. <br /> DATA PROCESSING COPY • <br /> 11IL <br />