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"EP'iuc�iii'T�e <br /> STATE OF CALIFORNI WATER RESOURCES CONTRCL. BOARD V �1 <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �'IIIFOR�P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> MARK ONLY ❑ ❑6 TEMPORARY SITE CLOSURE CA <br /> ONE ITEM [:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 'w <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS <br /> INFORMATION <br /> FACILITY/SITE NAME <br /> <. �' �4" ✓ ✓AaK o male ❑ PM1NBi511P ❑ SiAiEAGENLY <br /> NEAREST CROSS STREET CCNPORATIDN C] LDCAL-AGENCY ❑ FEDERAL AGENCY <br /> ADDRESS ��` x G'/!�)J, / �� `��l ❑ INDN[OIIAL C] lr,ll -AGENCY <br /> /F STATE ZIP CODE ./yn L� SITE PHONE#,WITH AREA CODE <br /> CITY NAME 'i ✓ CA 2 <br /> Box I EPA IDN #BI NIS SI <br /> TYPE BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR RESERVATION or ❑ .M AT TRIS SITE <br /> �1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ' <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> PHONE N WITH AREA CODE <br /> DAYS'. NAME(LAST,FIRST) PHONE b WITH AREA CODE DAYS. NAME(LAST,FIRST) "�/C/76% / , l <br /> "- PHONE#WITH AREA CODE <br /> NIGHTS. NAME(LAST FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST FIRST) e / <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BECARE OFDDRESS COMPLLETEoD) <br /> NAME <br /> ✓Box to intlicale ❑ PARTNERSHIP 11 STATE-AGENCY <br /> MAILING or STREET ADDRESS o ,I' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDEflAL-AGENCY <br /> r/`�.J �t 6 v ��✓/ (/f'\SVT ❑ INDIVIDUAL ❑ COUNTY-AGEN PHONE p,WITH AREA CODE <br /> /\ / </ I.�1 STATE ZIP Cl <br /> � <br /> CIN NAME r, <br /> c! 5t <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> OF ADDRESS INFORMATION <br /> OMPLETEDMATION <br /> [NA t �' <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> G or STREET ADDRESS <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEOERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENPHONE q,WITH AREA CODE <br /> STATE ZIP CODE <br /> NAME <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.:pJ II• ❑ III•❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY #o1TANKS at SITE <br /> AGENCY# <br /> FACILITY ID# <br /> COUNTY# JURISDICTION <br /> 4 <br /> m � / � 5 � U v <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> CURRENT LOCAL AOENCY FACILITY 1%M <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED DATE FILED <br /> SUPERVISOR-DISTRICT CODE NO ❑ <br /> LOCATION CENSUS TRACT* YES ' <br /> FEE CODE RECEIPT# BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S);,2ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-BS) <br /> 16 FU c CODS �t �� <br />