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STATE OF CALIFORNMA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE 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 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) CD <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> c <br /> M <br /> ADDRESS NEAREST CROSS STREET ✓ TD PAANED STATE AGENCY <br /> El 00WOMON ❑ LocALAGEAw ❑ REDEW-AGENCY <br /> 1 e D iNONOM D toONT AGENCY <br /> CITY NAME STATE i SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box d INDIAN EPA ID# M of TAOISTS <br /> ❑ ATION <br /> t GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING te STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING tx STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> I <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: L ❑ II. ❑ IS.❑ <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 /> it <br /> LOCAL AGENCY USE ONLY <br /> COUNTY E JURISDICTION S AGENCY R FACILITY ID N R of TANKS N SITE <br /> 118 115 1 2 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPR VED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L"EK7 <br /> DE CENSUS; # SUPERVISOR-013-MICT CODE BUSINESS PUN FILED DATE ILE <br /> YES NO ❑PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# B <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(3-2-88) <br /> '� DATA PROCESSING COPY .fir <br />