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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD «`.'""`" <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Io z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �""°""'� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 63 cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) C,TI <br /> N <br /> FACILITY/SITENA' / CARE OF ADDRESS INFORMATION <br /> PN J <br /> ADDRESS r NEAREST CROSS STREET 0✓Swo ON 0 Gt�EIMPPY O❑ STATE �Y <br /> Z I S ❑ INDIVIDUAL 0 CDATYJAGENO <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREACODE <br /> rk_149^/ CA 520,1"' <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓ IAN EPA ID A R al TANK'a <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TFBoz K INDINI UST LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME `` CARE OF ADDRESS INFORMATION <br /> RJ <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> e :/ <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. In If. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION k AGENCY k FACILITY ID a It of TANKS at SITE <br /> 1 O c <br /> CURRENT LOC AGENCY FACILITY ID APPROVED BY NAME PHONE k WITH AREA CODE <br /> n I^' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAnON CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED <br /> ,Z -2S YES ❑ NO 6 <br /> CNE PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> ITHIS 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 /> J FORMA(3-2-B8! <br /> ;ATA PROCESSING COPY <br />