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STATE OF CALIFORNIV WATER RESOURCES CONTROIBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 1 <br /> 74 COMPLETE THIS FORM FOR EACH ACILITY/SITE •�^=`" <br /> MARK ONLY ❑ 1 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 3 -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 0 <br /> F-� <br /> FACILI SITE NAME CARE OF ADDRESS INFORMATION <br /> P /3I&C <br /> � <br /> ADDRESS NEAREST CROSS STREET ✓BulDiMi[ale 0 PARTNERSHIP 0 STATE AGENCY <br /> ON 0 LOCAL AGENcy El/OCA ❑ BIVIB1I ❑ COUNTY AGENCY FEBEAAL AGENCY <br /> CITY NAME STATE ZI CODE SITE PHONE R,WITH AREA CODE <br /> zo CA �32� <br /> TYPE OF BUSINESS: DLJ 2 D IBUTGR F—] 4 PROCESSOR ✓Box it INDIAN EPA ID R <br /> I GAS STATION 3 FARM O <br /> ❑ 5 OTHER RESERVATION or AT THIS SITE <br /> of TANK's <br /> 1:1 TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME O CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 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. 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION R AGENCY A FACILITY ID k #of TANKS at SITE <br /> M = = I I 141 DIA ,:5 <br /> CURRENT.1.ofAAL AG ACILIJY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER o]\ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> DE CST T k SUPERVISOR-UjSTRICT CODE BUSINESSPUN FILED NO ❑ DI17E FIL D <br /> 3 3 D S L/[/ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT x BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-BB) • 0 <br /> DATA PROCESSING COPY <br />