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i <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Qp <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONoCOMPLETE THIS FORM FOR EACH FA L ITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CA) <br /> 00 <br /> FACILITY/SIT NAMEv CARE OF ADDRESS INFORMATION <br /> R 1� <br /> ADDRESS NEAREST CROSS STREET ✓Bm n#0ca, ❑ PABTNENSW ❑ STATE­AGMCY <br /> ❑ CGRPGFi ❑ LOCAL AGENCY O FEOER4.ACiEN,Y <br /> O ''T�t 11IWIVIWN ❑ COLAlY AGENCY <br /> CITY NAME STATE ZIPCODE SITE PHONE I.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. 2DISTRIBUTOR4PROCESSOR '/Box If INDIAN EPA IDN <br /> ❑ RESERVATION or a of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE v <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE F WITH AREA CODE NIGHTS: NAME("ST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 I` <br /> MAILING or STREET ADDRESS I/Box to indicate O PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. <br /> ❑ II. ❑ 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 /> COUNTY M JURISDICTION M AGENCY N FACILITY ID B N of TANKS at SITE <br />' m = = O o o o <br /> CURRENT LOCAL 7CY FACILITY ID Y APPROVED BY NAME PHONE N WITH AREA CODE <br /> �'�VI..�J\\ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTLCODE BUSINESL DATE 1 FTIL G <br /> NO lU l 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOEE CODEEIPT0 B <br /> THIS FORM MUST RE ACCOMPANIED BY AT LEAST(1`-^MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLF"^THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PHiUCESSiNG COPY ,� 1 <br />