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271 A717Z ®7- CxL ny m[�a WATER RESOURCES CONTROL BOARD <br /> FORIL `A'. <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION S , �� <br /> C_ COMPLETE THIS FORM FOR EACH FACILITY/SITE C,('FOR"P <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT li2<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE �=-) <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE LEI <br /> �) <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FA /SITE NAME CARE OF ADDRESS INFORMATION (�!� <br /> ADDRESS NEAREST CROSS STREET V�96 Micae ❑ PARTNERSH'P ❑ STATE-AGENCY ` <br /> CORPORATION ❑ LOM-AGENCY ❑ FEDERAL-AGENCY <br /> A-Ae. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE _ <br /> CA - IS <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 5PCESSOR ✓Box if INDIAN EPA ID It <br /> TRUSTLANDS <br /> Or ❑ /vt _t_ 11 of T O <br /> ❑ 1 GAS STATION ❑ 3 FARM Ej� OTHER 1ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> "1 <br /> ASC rr �d . n ?b 6_ c <br /> NIGHTS: NAME(LAST, IRST) PFIONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ElPARTNERSHIP ElSTATE-AGENCYEl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - ( UST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDI711122IIII SHOULD BE USED FOR DOTH GAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO HE 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# FACILITY ID# #of TANKS at SITE <br /> El .- I I 1016111AIaLr-1 LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> /^ <br /> PERMIT NU' ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 61 YES E] NO E] m/yo <br /> CHECK# PERE21T AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> _J <br /> THIS FORD MUST BE ACCO:PANTED BY AT LEAST(1)OR L70RE TANK PERVIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE IHFORL"ATION ONLY. <br /> FORM A(3-2-88) <br /> �� DATA PROCESSING COPY �.' <br />