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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': " � � <br /> UNDERGROUND STORAGE TANK PROGRAM =� m" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1.-► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> O <br /> FACILITY/SITE NAME CARE OF ADORES INFORMATION <br /> ct u hes <br /> ADDRESS NEAREST CROSS STR T ✓Bw bnEUV D PMNEMW 1:1STATEAGDIGY <br /> 3�8 >✓f r�e� O Iwffl�olwlT ON 0ICOAWAAGENC 11 %W AG NY <br /> CITY NAME STATE ZIP O E SITE PHONE N.WITH AREA CODE <br /> a N CAS <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz it INDIAN EPA ID N N of TANK1 <br /> ❑ I GAS STATON ❑3 FARM la 6 OTHER TRUSTYLANDS oI ❑ a o T ANK's E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) i <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE III <br /> NIGHTS: AME(LAST,FIRST4 PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> u 0 z -.z/// <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> mG` S <br /> MAILING or 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 p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a`57 AS : <br /> MAILING or STREET ADDRESS ✓Box to Indicate Cl PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ 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: 1., ❑ 11. 0III.❑ <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&SIGNATURE) DATE <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY 10 Al N of TANKS at SITE <br /> EE = = 3 Ito 5- 2 d D <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA COOE <br /> PERMI UMBER20 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILEO <br /> YES [:] NO / Z <br /> CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST I' 1 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA 13-2-1)8) �- � <br /> `R 1'� �" DATA PROCESSING COPY <br />