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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD '`x <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> I T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' : ; <br /> A COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��.ee��" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY OSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/NAME. t' kiK CARE OF ADDRESS INFORMATION <br /> ADORE58 NEAREST CROSS STREET ✓SMIOi D PAATWWIP 0 STATE AGFNGY <br /> I e �--� /`� D 0OWRAOON D LOCAL AGE10 D FEOEM AGB+Gv <br /> ❑ MWIDLW. D CG»RYAGENCY <br /> CITY NAME / STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> I`.OGL1 CA <br /> TYPE OF BUSINESS. ❑2 DI IBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> ❑ 1 GA6 STATION FARM 5 OTHER RESERVATION or y y�x_� AT TNI$SITE <br /> ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Fir, pi <br /> ayL <br /> NIGHTS: NAME(LA T,FIRST) �� p PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> _ -6_ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STR&T ADDRESS ✓Box Ie inoicate D PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S / <br /> MAILING or ST ET ADDRESS ✓Box to Indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION R AGENCY R FACILI DJ S o/TANKS at SITE <br /> 3 6 1 Sf y '?� opo / <br /> CURRENT LOCAL AGENCY FACILITY ID NN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT♦ SUPERVISOR-DIST111CT CODE BVSIMESS P$N F❑REO NO ❑ �A I <br /> a aa- aa-- <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-58) J` <br /> +!' �� <br />