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�qw <br /> STATE OF CALIFORNO WATER RESOURCES CONTROi:'BOARD <br /> FORM A: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> & COMPLETE THIS FORM FOR EACH FACILITY/SITE AL RN P <br /> F <br /> MARONLY 9-1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE fV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> m <br /> I. FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> FAITEKAME CARE OF ADDRESS INFORMATION <br /> i5EC'Ii <br /> ADDRESS J NEAREST CROSS STREET V Box tomicate 1:1 PARTNERSHIP El STATE-AGENCY <br /> E CORPORATION 0 LOCAL-AGENCY EFEDERAL-AGENCY <br /> L21,31 ?r_-4cl,1�C El INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE .SJTE PH NE#,WITH AREA CODE <br /> 4 PROCESSOR INDIAN CA qE5,-;� <br /> TYPE 0 USINESS: F—] 2 DISTRIBUTOR x f TI EPA ID # # <br /> TREjSBEORVA ON or of TANK's <br /> T <br /> 71GASSTATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ 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 4 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 1:1 LOCAL-AGENCY El FEDERAL-AGENCY <br /> 11 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS V Box to indicate E] PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATION El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 11 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE AI.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: I. D III. 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> IAPPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVO BY AME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERM V EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F17D <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) <br /> I z^— DATA PROCESSING COPY <br />