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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEX; FACILITY/SITE, INFORMATION anti/or PERMIT APPLICATION ' / <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLLISED SITE <br /> ONE ITEM ❑2 INTERIMPERMIT ❑ N AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5 <br /> 1. FACILITY/SITE INFORMATION S ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAM/\y..E f 4 CARE OF ADDHESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BabV [IikAt ❑ PARTW STATE44100 <br /> 7 ❑ OW MTDN ❑ LOCKAGDIEY ❑ FRIDW.-WENLI' <br /> ❑ YNYDWI ❑ CUM AGOILY <br /> CITY NAME STATE ZIP CODE SI TE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑p DISTR ❑N PROCESSOR ✓Box if INDIAN EPA 10 N <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER 7pSEjYj ANDS ❑ TAT SITE <br /> TIO <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE N 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 /> MAILING or STREET ADDRESS ✓Boz to ind,cMe 11PARTNERSHIP 11STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL O COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IIS. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lo,no,cam, ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE C 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: 1. ❑ 11. ❑ 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) PATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY 10 N N of TANKS At SITE <br /> H�l = I I I / 3F <br /> CURRENT LOCAL AGENCY ILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TIIACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OA LED <br /> YES [:] NO ILDCNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST P ^t MC" 'AHK PERMIT FORM 'B'APPLICATION(S), ups, "4 TW' ACHANGE OF SIl"E INFORMATION <br /> 1 FORM A(3-2-63ONLY. <br /> ) '� J �� `� <br />