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1 <br />STATE OF CALIFORNI WATER RESOURCES CONTRO BOARD <br />/ '•fiUMFM�•'•�F <br />FORM `A': =m <br />UNDERGROUND STORAGE TANK PROGRAM <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE C"OFp RN P <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑Kz5MAW4TLY LOSED SITE <br />ONE ITEM ❑ 2 INTF,RIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NA <br />:sh <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREETNADDRFS <br />ADDRESS <br />r `^ I <br />NEAREST CROSS STREET <br />✓Box to indicate <br />❑ CORPORATION <br />❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />1-1LOCAL-AGENCY ElFEDERAL-AGENCY <br />V W �1/ <br />❑ INDIVIDUAL <br />❑ INDIVIDUAL <br />❑ COUNTY -AGENCY <br />CITY NAME <br />_96 <br />STATE <br />ZIP CODE <br />-3 <br />SITE <br />PHONE #, WITH AREA CODE <br />Z� V3S,- S'Z8 <br />B <br />CA <br />3 7 <br />- <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR❑ 4 ROCESSOR <br />*/Box if INDIAN <br />EPA ID # <br /># of TANK's <br />❑ 1 GAS STATION [:]3 FARM <br />5 OTHER <br />RESERVATION or <br />TRUST LANDS ❑ <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (,LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAMEa I <br />t-kS?S <br />CARE OF ADDRESS INFORMATION <br />CURRENT LOCAL AGENCY FAC ID # <br />N , C* <br />MAILING or STREETNADDRFS <br />✓ Box to indicate <br />❑ PARTNERSHIP <br />❑ STATE -AGENCY <br />'J rq <br />El CORPORATION <br />1-1LOCAL-AGENCY ElFEDERAL-AGENCY <br />l 1 <br />V ('� <br />❑ INDIVIDUAL <br />ElCOUNTY-AGENCY <br />PHONE #, WITH AREA CODE <br />CITY NAME <br />STATE�,cA� <br />ZIP CQODE (� <br />PHONE #, WITH AREA A}R�E-'AA CCODE �1 <br />mp �-}- <br />B <br />0 <br />Ws - <br />III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME (1 <br />CARE OF ADDRESS INFORMATION <br />CURRENT LOCAL AGENCY FAC ID # <br />N , C* <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />PERMIT APPROVAL DATE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <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: I. ❑ if. ❑ 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 & SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />[3a <br />JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE <br />1 1 1 -1 [:1 1 1 1 1 111 I o:Ul_ <br />CURRENT LOCAL AGENCY FAC ID # <br />N , C* <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />D <br />CENSUS TRACT # <br />SUPERVISOR -DISTRICT COD <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />DATE FILED <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />B <br />THIS -FORM MUST BE ACCOMPANIED BY AT LEA) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. <br />FORM A (3-2-88) <br />,Yf _ ) DATA PROCESSING COPY 0 <br />z <br />10 <br />N <br />O` <br />J <br />w <br />