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STATE OF CALIFORNIA" WATER RESOURCES CONTROL*ARO <br />FORM `A': <br />UNDERGROUND STORAGE TANK PROGRAM <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FVNM FUR EACH F ILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST RE CORAM FTFnl <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />✓ Bax to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br />ADDRESS <br />NEAREST CROSSSTREET <br />✓Sort)W.N ❑ PARTNERSHIP ❑ STATE'AGENC( <br />❑ <br />CITY NAME <br />STATE <br />N�i� <br />FEDERAL.AGENLY <br />o 0 COALANTYGE C <br />LOCATION CODE <br />CENSUS TRACCTT41 <br />p a <br />IDryRPGRALIGN <br />CITY NAME <br />DATE FILED <br />] O <br />STATE <br />ZIP CODE <br />SURCHARGE AMOUNT <br />SITE PHONE #, WITH AREA CODE <br />FEE CODE <br />RECEIPT It <br />CA <br />BY: /.. <br />TYPE OF BUSINESS: F—] p DISTRIBUTOR <br />❑ 4 PROCESSOR <br />Box it INDIAN <br />EPA ID # <br />❑ 1 GAS STATION ❑ 3 FARM <br />❑ 5 OTHER <br />LANDS ATION D ❑ <br />TANK'# <br />TRUST <br />AoI <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE It WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION A ADDRESS — fUl ICT RF rnUni Crrnl <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Bax to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br />N of TANKS at SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY L] FEDERAL -AGENCY <br />APPROVED BY NAME PHONE; WITH AREA CODE <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE N. WITH AREA CODE <br />III. TANK OWNER INFORMATION A AnnRFSR _ iRAI Lc -r RF nnum =vcm <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br />N of TANKS at SITE <br />❑ CORPORATION Cl LOCAL -AGENCY ❑ FEDERALAGENCY <br />APPROVED BY NAME PHONE; WITH AREA CODE <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE R, 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: 1. ❑ 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 6 SIGNATURE) <br />LOCAL AGENCY USE ONLY <br />DATE <br />COUNTY # <br />JURISDICTION k <br />= <br />AGENCY # <br />FACILITY ID N <br />I I I A/ 13-13 <br />N of TANKS at SITE <br />CURRENT LOCAL AGENCY E CIL ID Al /A / <br />APPROVED BY NAME PHONE; WITH AREA CODE <br />PERMIT NUMBER <br />PENMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACCTT41 <br />p a <br />SUPERVISOR -DISTRICT CODE <br />.3 t— <br />BUSINESS PLAN FILED <br />YES [-] NO <br />DATE FILED <br />] O <br />CHECK# <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT It <br />BY: /.. <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST"' 08 MORETANKPERMIT FORM 'B' APPLICATION(S), v" CSS THIS IS A CHANGE OFSITE INFORMATION Y. <br />FORMA (3-2A6) <br />'�+ DATA PROCESSING COPY '+^1 <br />z <br />I ct' <br />N <br />Qi <br />RTd <br />N <br />q <br />