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e 3w'RE". a;•a e'N"Rh9 '$^ '. .. ... - ;�`-'g „�._ a R r rre•rs - f <br /> ASTATE OF CALIFOR WATER RESOURCES CONTROL BOARD <br /> FORM `A': w9m <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH ILITY/SITE �FC tk P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT El TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CG <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G/4]_ W <br /> ADDRESS �l� NEAREST �S"S�S�TREET ✓ xtoindicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> O� F S4_i ) , SS <br /> id ❑ INDIVIDUAL 13 <br /> 13 COUNTY AGE CY ❑ FEbERAL-AGENCY <br /> CITY NAME � j/ STATCA ZIP COD � SIJE PHONE H,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROC SSOR ✓Box if INDIAN EPA ID nj� e� #of TANK's <br /> ❑ 1 GAS STATION <br /> [:]3 FARM HER TRUSRESETvLANDS or ❑ / AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR B TH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> M I I I I EI I 1 0G1 1 / B-M ® moo <br /> CURRENT LOCAL AGENCY FACI ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE p,L.� <br /> D YES ❑ NO ❑ I 417749T74,_/` <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOU T FEE CODE RECEIPT# B <br /> s <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEA )OR MORE TANK PERMIT FORM`B'APPLICATION(S), UNLESS THISIS CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) ^ v <br /> `l7s (L/) `bo DATA PROCESSING COPY <br /> I <br />