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STATE OF CALIFORN* WATER RESOURCES CONTRbeBOARD <br /> 4 yE" r1f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Q J' <br /> = <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY QLOSED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 010 <br /> OD <br /> FACIUTYBITE NAME /� CARE OF ADDRESS INFORMATION <br /> S DL - <br /> ADDRESS NEAREST CROSS STREET <br /> ❑ PBME-RSHIP 1-1 STATE-AGEY GB=ol ❑ LOCAAGECY ❑ FEI)MAGI <br /> j: 6/tsf Avar <br /> 13 INDMDUA ❑ i:xXwAGENCY <br /> CITY NAME STATE ZIP CODE SI PHONE p,WITH AREA CODE <br /> 4.+tmvp CA 33 a s si <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PNCESSOR ✓Box i1 INDIAN EPA ID N Npf TANII <br /> RESERVATION <br /> ❑ I GAS STATION ❑3 FARM OTHER TRUST LANDS ur ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRSTI PHONE N WITH AREA CODE <br /> v" loaf PSS"-S/S/ <br /> NIGHTS: NAME(LAS FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS wIIW ✓ oindicate O PARTNERSHIP ❑ STATE-AGENCY <br /> �/ _ /- ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> [4.(j(� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STO ETvQ PARTNERSHIP STATE-AGENCY <br /> �pN ✓ ROON O LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> f.S S/S�/ <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION B AGENCY N FACILITY ID It M 01 TANKS at SITE <br /> CURRENT LOC,L AGENCY FACILITY ID 0 /1 APPROVED BY NAME PHONE N WITH AREA CODE <br /> v SD <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONN.CODE CENSUS TRACT F SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILE(D��'G/ <br /> YES NO � / O / <br /> ` I CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 /> V FORMA(3-2-ee) S <br /> 1..� DATA PROCESSING COPY wll( <br />