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tt� k <br /> STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EAC2 FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I--a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> -J <br /> FACILITY/SITE NAME. CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bm to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CDRPORANON ❑ LOCAL-AGENGY ❑ FEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NA STATE ZI CODE SITE PHONE It,WITH AREA CODE <br /> off V///V- CA I2 <br /> TYPE OF BUSINESEY <br /> ❑ p p RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'# <br /> ❑ 1 GASSTATION FARM ❑ S OTHER TRUST LANDS ❑ AT 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 /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME � ^ I CARE OF ADDRESS INFORMATION <br /> Al0 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /. ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGEOCY <br /> CITY AME 4W r STATE ZIP CODE PHONE#.WITH AREA CODE <br /> e l 1/1I S <br /> TANK OW ER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAhi <br /> /) CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME 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. ❑ it. 2, 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 b <br /> COUNTY# JURISDICTION At AGENCY# FACILITY ID# SO #of TANKS at SITE <br /> O0 <br /> CURRENT LOCAL AGENCY FACILI/1 # APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCCAAT�IfJ�N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z 3�� YES NO <br /> CHECKN PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE AC ANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> Ian/ FORM A(3-2-BB) <br /> u _ DATA PROCESSING COPY <br />