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Y <br /> STATE OF CALIFORNrx' WATER RESOURCES CONTRA BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> 1 Z <br /> SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PaRUI CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS 9 /�� NEAREST CROSS STREET ✓BmbnEieat 0 PWN81SHP 0 STATE-AGENCY <br /> /�1 /D / � K 11 CORPORATION 0 LDGL.AWO 0 FWA,.AGBILY <br /> ❑ INDIVIDUAL 0 OWMAGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> �0 of 1 CA a <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRTVLANDS ATION or ❑ AT HIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRS ) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> wlo �� a0,✓R�o /V//, <br /> NIGHTS: NAME(LAST,FIRST)I 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 sCARE OF ADDRESS INFORMATION <br /> he a"� <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to intlicate 0 PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> [Sal00y 1 151oa <br /> CURRENT LOCAL AGENCY FACILIMD N APPROVED BY NAME PHONE N WITH AREA CODE <br /> O K <br /> PERMIT NUMBER PERMIT APPROVAL DATELFEE <br /> PERMIT EXPIRATION DATE <br /> IODATION CODE CENSUS TRACT k SUPERVISOR STM BUSINESS PLAN FILED DATE FIL D <br /> YES ❑ NO <br /> CHECK R ' PERMIT AMOUNT SURCHARGE AMOUNTODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IS'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. _ <br /> FORMA(3-2-813) _ S ' <br /> *two- DATA PROCESSING COPY Now <br />