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STATE OF CALIFORNIAO WATER RESOURCES CONTROLBOARD <br /> f <br /> W' <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> c , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMjwFNTIYQ6OSED SITE FV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ()/ <br /> ADDRES�� / NEAREST CROSS STREET ✓ rG¢ale 0 PARTNERSHIP 0 STATE-AGENCY <br /> RPGRATION ❑ LOCAL AGENCY ❑ FEOERAL-AGBICY <br /> Cl INOIYIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA IS3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PRQQQCCCESWR ✓Box if INDIAN EPA ID # <br /> ❑ � -,( RESERVATION or #of HIS SI <br /> ❑ 1 GAS STATION ❑ 3 FARM THER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> Zv 3 <br /> NIGHTS: NAME(LAST,F T) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> V/ <br /> MAILING or STREET ADDRESS ✓Box to inoicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ 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 /> �d <br /> MAILING or STREET ADDRESS ✓Bax to inoicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. ❑ it. ❑ 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# JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE <br /> / t— c 1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> MaDE72 // <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 4/ LOCATION CODE CENSSUUJS TTRACTTT* SUPERVISO�jR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / 11 <br /> vl �J D L 3,90 ✓2 YES NO !J-11� G(J <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S), U ESS THIS IS A CHANGE OF SITE INF ATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY � <br />