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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> V_•"P'a'y r 'T <br /> FORM ' <br /> A1.. UNDERGROUND STORAGE`TANK PROGRAMo <br /> SITE FACILITY/SITE,'INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY O!S ITE F <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEO PERMIT ❑6 TEMPORARY SITE CLOSURE- 00 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ Cik ❑ PAfIFNERS M ❑ STATE-AGM <br /> 7OlJ �. ❑ NDIV M 2 TION ❑❑ L COLNIYAGEN [3F FI.AGEkLI' <br /> CY <br /> CITY NAME STATE ZIP CO r SITE PHONE IV,WITH AREA CODE <br /> CA �3 9 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROLE TllESBE(14ATION <br /> if INDIAN EPA ID p 1f of TANK': <br /> or ❑ lATTHISSrrE <br /> ❑ 1 GAS STATION ❑3 FARM HER UST LANDS <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(LA ,RRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> ' NAME � ff� CARE OF ADDRESS_INFORMATION ' <br /> MAIL IH or STREET ADDRESS ✓BOx to Indicate ❑ PARTNERSHIP [:1STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY•AGENCY <br /> CK NAME STATE 7ZIP CODE PHONE N.WITH AREA CODE , <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION - <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLINQAdRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE S S LD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL ElIII.❑ <br /> THIS FORM HAS BEEN COMPLET((DWENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME <br /> LOCAL AGENCY USE ONLY <br /> FCOUNTY 11 JURISDICTION N AGENCY It FACILITY 10# N of TANKS at SITE <br /> [1�1 I I I - El I /I - o-l ' EcEl v a IET <br /> ENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE- <br /> LOCATION CODE CENSUS TRACT 4 SUPERVISOR-DI5TRICT CODE BUSINESS PLAN FILED DATE FI D <br /> o� '60 YES ❑ NO EDr� '/ i <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 Y. <br /> FORM A(3-2-88) G ' <br /> E DATA PROCESSING COPY <br />