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40 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �m <br /> SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN.EUL Y C.1 QqEDSITE 7j <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a •0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CAS <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> U WP�7 <br /> ADDRESS NEAREST CROSS STREET ✓Boxtavdi - ❑ PARTNERSHIP ❑ STATE AGENCY <br /> /P/, . aP/� ❑ C RON ❑ LOCAL ❑ FEDERAL AGENCY <br /> DNIDDAt ❑ COUNttAGENCY <br /> CITU NAME STATE ZIP CODE }� SITE PHONE p,WITH AREA CODE <br /> ca e x CA %S3e(/ _ _ s <br /> TYPE OF BUSINESS'. ❑ 2D IBUTOfl ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID It <br /> ❑ I GASSTATION 3 FARM ❑5 OTHER TRUSTLANDS VATION or ❑ #PI TANKED / <br /> Gt lG- ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rho ve .T <br /> MAILING or STREET ADDRESS ✓Box oodicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LJ yOAPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCYINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME Above .Z CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ,,✓Roxt indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LJ S:HHRD ATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# ACILITY ID If /##of TANKS at SITE <br /> V <br /> CU <br /> AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> jPERMIT ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 6 03aa- 3';E_(0 YES NO <br /> CHECK# PERMIT AMOUNT SURCHAgGE AMOUNT FEE CODE RECEIPT p By. <br /> �l�a <br /> L� 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. <br /> \{ORM A 13-2-681 - <br /> \\`vn�\'\ DATA PROCESSING COPY <br />