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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE H <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACI /SITE NAME - CARE OF ADDRESS INFORMATION <br /> D C <br /> ADDRESS NEAREST CROSS STREET ✓Oa 1.Wodk ❑ PNONEEHP ❑ SIATE#GENLY <br /> 3 75, <br /> S4TION ❑ LOCWAGENGY ❑ 0EML-AGDILY <br /> NI1: ❑ UDUNTYKOC/ <br /> CITY NAME STATE IP CODE SITE PHONE#.WITH AREA CODE <br /> CA 7j ap <br /> TYPE OF BU INESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓BOx B INDIAN EPA ID p <br /> [:] 1 GAS STATION ARM ❑ 1:15 OTHER TR 3TMLAAN Ot #of <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(RST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 /> els�r� <br /> MAILWGor STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> o <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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111.❑ <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# #of TANKS at SITE <br /> CURRENT�AL 7CY FACIL � APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER /'x'TT. PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA <br /> 7JQy.�ODE CE��SJTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLANFILED ❑ DATEFIl <br /> e7 <br /> 7,� �/yJ/Gp YES NO L/P <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY:1411 q- I <br /> I 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 /> \vn1I1 FORM A(3-2-88, <br /> ,� DATA PROCESSING COPY <br />