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TATE OF CALIFORNIA WATER RESOURCES CONTROL BOIG <br /> ORM 'A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE G FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 ' —4 <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> lG <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> - n rvnAm - maria , <br /> ADDRESS NEAREST CROSS STREET ✓9m(0 N't, 0 PARTNERSHIP 0 STATBAGENCY <br /> D CORPORATION 0 Logi 0 FEDERAL AGENCY <br /> 3a - ( / ( Q j,CL D INDIVIDUAL D COUNTYAGRI <br /> CITY NAME uu STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> (Y1 a.) m teCA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box it INDIAN EPA ID If <br /> RESERVATION or N of HIS SI <br /> ❑ 1 GAS STATION [:]3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinaicate Cl PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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 N JURISDICTION k AGENCY R FACILITY ID M 0 of TANKS at SITE <br /> E= U �� c) <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE At WITH AREA CODE <br /> is - R1L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C E CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> I� YES � NO 1 — L.' <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST#R MORE TANK Pi FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> /FORMA(3-2-SB) <br /> DATA PROCESSING COPY <br />