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.�f i <br /> STATE OF CALIFORNIA '' WATER RESOURCES CONTROL BOARD sE <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM ="° I <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ®' a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "IF.RI <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/!IIN <br /> NAME CARE OF ADDRESS FORMATION <br /> u �< <br /> ADDRESS NEAREST CROSS STREET ✓Bortntsuie El PARTNERSHIP ❑ S1ATE-AGENCY <br /> ❑ GOP.PORATION ❑ LOCAL-AGENU ❑ FEDERAL <br /> N ��✓ ❑ womouu ❑ courm-ACB+a <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> �p CA Z <br /> TYPE OF BUSINESS. ❑ ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID A A of TANK'# <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSTIATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREE DDRESS / ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> G..•lll✓flAf C4 9 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Me <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOX 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY R FACILITY ID k R of TANKS at SITE <br /> ffl = = I 1 10 / o <br /> CURRENT LOCAL AGENCY FACITTY ID# �� APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER C//`,• PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHEICKIN <br /> ION CODE CEN STRACT# SUPERVISOfl-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE FILED <br /> 2S. Z <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 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(3-2-88) \ <br /> �� DATA PROCESSING COPY <br />