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STATE OF CALIFORNIA WATER RESOURCES CONT o BOARD °: ' <br /> F I �. <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE •ae�`' 1-� <br /> MARK ONLY ❑ I 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 /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACIL TY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> IIa+ <br /> ADDRESS NEAREST CROSS STREET ✓BNbYgYae ❑ PMTMTMH ❑ STATE"NCY <br /> ❑ CWMTDN ❑ LOX AGENCY ❑ fENEAA WkNLY <br /> ❑ INAMM ❑ C"WAGENLY <br /> CITY NAME STATE ZIP ODE SITE PHONE Y,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESE <br /> ❑ 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUSTYLANDS OI ❑ Fol TANK'Y <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,FIRST) PHONEY WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONEY WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME H Ij T CARE OF ADDRESS INFORMATION <br /> MAILING STREET ADORE 5 /} ✓Bo.io m.cate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> I u� ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCYQ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMSTATE ZIPCODE PHONE p.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) rVy,/ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Boa to micate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE p,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. ❑ it. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> 1%�saaa <br /> JURISDICTION R AGENCY Y FACILITY ID F M of TANKS at SITE <br /> a <br /> CY FACILI IDYY WITH AREA CODE <br /> aPERMIT APPROVAL DATE PERMIT EXPIRATION DATEENSUSTRACTY SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIILEc23- Z0 YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST M OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UP' SS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />