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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD ; y` <br />FORM 'A': a�a <br />or <br />UNDERGROUND STORAGE TANK PROGRAM <br />SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE QS, <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLFTFOI <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING m STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />ADDRESS <br />2 <br />/�\ <br />NEAREST CROSS STREET <br />CITY NAME <br />-hcn <br />✓ to Moll Ll PARTNERSHIP 11 STATE AGENCY <br />❑ CORP 11LGCALAGEND <br />ZIP CODE PHONE A, WITH AREA CODE <br />�— <br />q 45(D(9 <br />TION 11FEDERALAGEND <br />BUSINESS PLAN FILED <br />YES ❑ NO E]CHECK# <br />DATE LED <br />PERMIT AMOUNT <br />❑ rolvlOOAL ❑ COUNttAGENCv <br />CITY NAME <br />FEE CODE <br />STATE ZIP CODE <br />SITE PHONE #, WITH AREA CODE <br />By; <br />TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR <br />❑ 4 PROCESSOR ✓ Box i11NDI, <br />EPA ID # <br />❑ 1 GASSTATION ❑ 3 FARM <br />❑ 5 OTHER RESERVATION or ❑ <br /># of TANK'S <br />TRUST LANDS <br />AT THIS SITE 3 <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE It WITH AREA CODE <br />DAYS. NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION A AnnaFcc _ tui Icy oe rn.al orin, <br />III. TANK OWNER INFORMATION A AnnaFcc _ rul lay me r^amm �r�... <br />NAME qq nn <br />CARE OF ADDRESS INFORMATION <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING m STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCALAGENCY❑ FEDERALAGENCY❑ <br />NAME <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />-hcn <br />STATE <br />ZIP CODE PHONE A, WITH AREA CODE <br />A' <br />q 45(D(9 <br />III. TANK OWNER INFORMATION A AnnaFcc _ rul lay me r^amm �r�... <br />NAME qq nn <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box lo,Hdo le ❑ PARTNERSHIP ❑ STATEAGENCY <br /># of TANKS SI SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTYAGENCYCITY <br />NAME <br />STATE <br />ZIP CODE <br />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. 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 8 SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY M <br />JURISDICTION # <br />AGENCY N <br />FACILITY ID # <br />O <br /># of TANKS SI SITE <br />CURRENT LOCAL AGENCY FACILITY ID # <br />2 - <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT # <br />SUPERVISOR -DISTRICT CODE <br />2 <br />BUSINESS PLAN FILED <br />YES ❑ NO E]CHECK# <br />DATE LED <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT* <br />By; <br />11110 PURIM MUSI BE ACCOMPANIED BY AT LEAST(1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A (3-2-88) /^� <br />g— L4 %I' DATA PROCESSING COPY <br />N <br />@i <br />r <br />V <br />Jln <br />