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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> „ <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m Aa o <br /> IV COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I W PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C SED SITE N <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) YW` <br /> FACILITY/SITE IJAME CARE OF ADDRESS INFORMATION42 <br /> ,v <br /> rA <br /> ADDRESS NEAREST CROSS STREET ✓Bmbibbae ❑ PIMNEPSNIP EAGENLY � <br /> ❑ COAPONAiIDN 0 LOCAL AGENCY FF➢IXIL-AGENCY <br /> Cl AGNIDIAL 0 WiJa YAGENCY <br /> CITY NAME STATE ZIP CODE 51TE PHONE#,WITH AREA CODE <br /> CA i2s3S_ s, <br /> S ' <br /> TYPE OF BUSINESS [_] 2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID p Mol TANK'# I IA)I <br /> RESERVATION or <br /> ❑ I GASSTATION ❑ 3 FARM HER TRUST LANDS 1:1 THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 0 $1 <br /> NIGHTS: NAM ST,FIRST) PHONE 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 ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> >� / ❑ POPPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> (J7/ , Q/�' J P}'TND"DUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE#,WITH AREA CODE <br /> / 3? <br /> III. TANK OWNER AFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or TREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> a 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME �- STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFIC ION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 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 k JURISDICTION R AGENCY M FACILITY ID k X1.9 k 1�? *of TANKS at SITE <br /> U I z U a lol 01 1— <br /> CURRENT LOCAL AGENCYACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE <br /> �3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISO -DISTRICT CODE BUSINESS PULN FILED DATE FILE <br /> O YES ❑ NO ❑ �� n <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST-M OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-813) - <br /> DATA PROCESSING COPY � S/ <br />