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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> Y A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <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 PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Wl <br /> a <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) d <br /> FACILITY/SITE CARE OF ADDRESS,INFORMATION <br /> NAME <br /> ADDRESS NEAREST CROSS RET ✓ rWMKM 0 PARTNERHF 0 STATE AGE119 Cjq <br /> CDAPOM71oN Cl LOCALAGENLY 0 EEOERAI-AGENCY Ava AX/F- <br /> INOMOUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP ODE ITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box tl INDIAN EPA ID # <br /> RESERVATION or X of TANK§ <br /> ❑ 1 GAS STATION ❑3 FARM �SOTHEfl TRUST LANDS ❑ 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 /> NOVE L <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) REA C <br /> HO N WITH AODE <br /> r✓ -43 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> M S S I <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 /> S , <br /> MAILING or STREET ADDRESS J Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> -_ 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME $TATE ZIPCODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH 130YE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: IJ4, II. ❑ l0.❑ <br /> li THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. r <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION R AGENCY B FACILITY ID At #of TANKS at SITE <br /> 1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I <br /> �20 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED L I <br /> O a3lgO Z YES ❑ NO O K. <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTM F t by: I <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 /> l ,FORMA(3-2-88) '- __ <br /> `V(/' `Jl �� DATA PROCESSING COPY X49 <br />