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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': s <br /> UNDERGROUND STORAGE TANK PROGRAM =` \m <br /> SITECiLITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPILE THIS FORM FOR EACH FACILITY/SITErra <br /> Cy _ <br /> IIFO RNiP IA <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑59?mTE <br /> N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE l� <br /> Lin <br /> I. FACILITY/SITE INFORMATION &ADDRESS -- (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEARESTCRO STREET ✓t3oMtoindicale ❑ PARTNERSHIP ❑ STATE-AGEN(.Y <br /> �^ '^}'f �J. ❑ WRPGRATfON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> l v v ❑ INDIVIDUAL ❑ CwM-AGENCY <br /> CITY NAME STATE ZIP CO E SITE PHONE#,WITH ARE CODE <br /> CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS or ❑ AT THHISIS SSI#of S <br /> TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ST,FIRST LN ONE#WITH AREA CODE DAYS: NAME(LAST,F T) PHONE#WITH AREA CODE <br /> e�. A9 4315--210 <br /> NIGHTS: NAMI(LA ,FIRST) PH NE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME {`] CARE OF ADDRESS INFORMATION <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 I ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /SCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS(//�`/_�_L•,f J/ ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FFDFRAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / l Doloy— <br /> CURRENT <br /> LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 6 <br /> YFORMA(3-2�-88) <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> 3 v Q YES ❑ NO ❑ Z 9+J <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> T BE ACCOMPANIED BY AT LEA")OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> �� DATA PROCESSING COPY <br />