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STATE OF CALIFORNI► WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'J <br /> ONE ITEM -4❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> O <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREETmMost 0 PARTNERSHIP 0 STATE-AGENCY <br /> U "l S f' CORPORATION 11LOXAGENCY ❑ FEDERAL-AGENCY <br /> / ` ❑ INDIVIDUAL ❑ CWNTKAGENCY <br /> CITY NAME �1(�"��� STATE ZIP CODE SITE PHONE It.WITH AREA CODE <br /> QN/�-'"� CA25-336 <br /> TYPE OF BUSINESS: ❑2 IBUTOR ❑ 4 PROCESSOR M`1:1 <br /> gOx if INDIAN EPA ID N <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRESTT�ESERVLANDS UATIIf of TANK's <br /> ❑ ATT IS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS- NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> eA I Irle o,� <br /> MAILINGor TRELT A ESS 1/Dox to Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> [J ^ ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> / 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE$1,WITH AREA CODE <br /> ti C g <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 11 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L E 1L Tl uL❑ <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 k JURISDICTION K AGENCY N FACILITY ID R IF of TANKS at SITE <br /> I 1 1 V 10o0 <br /> CURRENT ED GEN Y.FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER OL/L /J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONE CENSUS7'ACTN SUPERVISOR-DISTRICT CODE BUSINES;P SNFILED NO ❑ DAT,LE7g PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N b/J YBY: <br /> 41 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 /> FORM A(3-2-SW) - <br /> DATA PROCESSING COPY L� <br />