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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 5E♦' lM <br /> W <br /> FORM 'A': "��`�' <br /> UNDERGROUND STORAGE TANK PROGRAM =" �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE ""�°%� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT Er5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ R 0 PAFfIRmlflp 0 STATE-AGENCY <br /> �,/� WAPDMTION 0 M&AGBICY 0 FEDERAL-AGENCY <br /> C 0 1 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> CA S Zo9-`fy373 <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑4 ESSOR ✓Boz if INDIAN EPA ID # <br /> RESERVATION or #of TANMs <br /> ❑ 1 GASSTATION ❑ 3 FARM EV5 OTHER TRUST LANDS ❑ ATTHISSITE <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 &ADDRESS - (MUST BE COMPLETED) <br /> NAME � � CARE OF ADDRESS INFORMATION <br /> ✓� �r YY Pil <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP D 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 /> Z n Z7 <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 77 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ It. z 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 If AGENCY# FACILITY ID# #of TANKS at SITE <br /> Da <br /> CURRENT LOCA AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> /woo N /a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �7 <br /> D/ 3� 3� YES NO E] 71'70 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> Foam A.'I,. 8 <br /> DATA PROCESSING COPY <br />