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STATE OF CALIFOR WATER RESOURCES CONTiL BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM Wm <br />abo <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE oR"" <br />MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ANENTLY E SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME r <br />p� y <br />CARE OF ADDRESS INFORMATION <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />CURRENT LOCAL AGENCY FAfrILITY ID # ' <br />'V <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />ADDRESS <br />, <br />NEAREST CROSS STREETindcate <br />❑ PARTNERSHIP ElSTATE-AGENCY <br />/ <br />l <br />PHONE #, WITH AREA CODE <br />❑ IN ❑ FEDERAL -AGENCY <br />CENSUS TRAC # <br />Z r 0 <br />SUPERVI R -DISTRICT CO <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />ClORPORATION <br />INDIA UAL ❑ COUNTY -AGENCY <br />CITY NAME <br />PERMIT A OUNT <br />STATE <br />ZIP CODE <br />SITE PHON #, Wlj� AREA DE <br />RECEIPT # <br />BY: <br />��x-51 <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />❑ 4 CESSOR <br />✓ Box if INDIAN <br />EPA ID # <br /># of TANK'a <br />❑ 1 GASSTATION ❑ 3 FARM <br />5 OTHER <br />RESERVATION or <br />TRUST LANDS ElAT <br />THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY C"TACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LA , FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NMit (LAST, FIRST) PHONE # WITH AREA CODE <br />11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST* COMPLETED) <br />NAME <br />C 'OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />CURRENT LOCAL AGENCY FAfrILITY ID # ' <br />'V <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />APPROVED BY NAME PHONE #WITH AREA CODE <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />111. TANK OWNER INFORMATION & ADDRESS — 01116ST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />CURRENT LOCAL AGENCY FAfrILITY ID # ' <br />'V <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />APPROVED BY NAME PHONE #WITH AREA CODE <br />Cl INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />IV. LEGAL NOTIFICATION AND BILLING AbDRESS <br />I CHECK ONE (11) BOX INDICATING WHICH ABOVE ADDIS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III. ❑ <br />THIS FORM HAS BEEN COMPLETED <br />APPLICANT'S NAME (PRINTED & <br />LOCAL AGENCY USE ONLY <br />TY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />DATE <br />COUNTY # <br />JURISDICTION <br />AGENCY # <br />FACILITY ID # # of TANKS at SITE <br />LLO ( �b UCS <br />CURRENT LOCAL AGENCY FAfrILITY ID # ' <br />'V <br />APPROVED BY NAME PHONE #WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION DE <br />O <br />CENSUS TRAC # <br />Z r 0 <br />SUPERVI R -DISTRICT CO <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />DATE FIL <br />y <br />CHECK # <br />PERMIT A OUNT <br />SURCH GE AMOU <br />FEE CODE <br />RECEIPT # <br />BY: <br />��x-51 <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 ONLY. <br />FORM A (3-2-88) <br />DATA PROCESSING COPY <br />10 <br />