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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � - <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PE MANE LOSEO SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS -' (MUST BE COMPLETED) <br /> FACtLITYISITE NAME CARE OF ADDRESS INFORMATION <br /> W� <br /> ADDRESS NEAREST CROSS STREET ✓Bab 6 W ❑ PAM ❑ STAIEAGD Y <br /> ❑ ODWMTCN❑ ❑❑ `LC -M 11RM!-AWV <br /> CITY NAME STATE ZIP CODE - SITE PHONE k,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTR OR ❑4 PROCESSOR ✓Box I(INDIAN EPA ID It <br /> RESERVATION or 0 M TANK s <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS S11E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 11 WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION S ADDRESS -- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ;I <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE 0.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY 9 <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BIL KESS <br /> Nf <br /> CHECK ONE(1)BOX INDICATING WHICH ARO E"SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ IR.❑ <br /> THIS FORM HAS BEEN COMPL �D 'PAOPENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(P E b RE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ENUMSER <br /> JURISDICTION N AGENCY* FACILITY 1D R A of TANKS at SITE <br /> [all I Ila- Li T_/ 14? 14/El I I I E�� <br /> LL <br /> GEENCYCY FACILITY ID• APPROVED BY NAME PHONE II WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> x <br /> CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT A BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'AMJCATIOH(SJ UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) r- _ <br />