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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD %z <br /> S <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONIt 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 11 l<„olx �P IL <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G. <br /> -,57:3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CA F ADDRESS INFORMATION cc <br /> ECo 1C�V M N`� MPI <br /> C. <br /> ADDRESS <br /> NEAREST CROSSSTREET C.to ural¢ 0 PARTNERSHIP 0 STATE-AGENCY <br /> 2Oby D -� 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> (� ❑ INDIVIDUAL 0 COUNTY CITY NAME STATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> �d oN CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓ EPA 10 q <br /> ❑ Box if INDIAN <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION <br /> or ❑ #of TANK's <br /> TRUSTAT 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 It WITH AREA CODE <br /> NIGHTSNAME(LAST,FIRST) PHONE It 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 intlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> El CORPORATION ❑ LCAL-AGENCY 0 FEDERALAGENCY❑ INDIVIDUAL ❑ CO NTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE AGENCY <br /> 0 CORPORATION ❑ LOCALAGENCY0 FEDERALAGENCY❑ INDIVIDUAL Fl COUNTY-AGENCY <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. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCYLIF FACILITY ID# / #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE Jr WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE Ii <br /> -3 Z r YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE (1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS) NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. � <br /> FORM A S 2-88) A <br /> DATA PROCESSING COPY <br />