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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5• ` ` a <br /> FORM `A': _ �'m <br /> UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �. <br /> C1L,fOPN�P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P ENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NEAREST OR OSS STREET ✓Bmibilisb ❑ I'AIIMMNP ❑ FEDERAL A6Fr <br /> ADDRESSQ` XI,,'P .X/.� E�I� ❑ CDPPOM➢BN ❑ IOCN#GENLV ❑ RfIFAAL-AGkICr <br /> a Flo / X�• �!X "A/ O NM'MK o CON7Y.AGBICY <br /> CITY NAME / STATEZIP ODE SITE PHONE#.WITH AREA CODE <br /> CA Jt <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4P ESSOR RESERVATIONBox <br /> itINDIAN <br /> or EPA ID # ATTHIS SITE <br /> E] 1 GAssTAT10N ❑3 FARM DTHEA TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME( PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> LorUST,FIR har a - <br /> NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S CL-rl, _ <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME C nC CARE OF ADDRESS INFORMATION <br /> a <br /> J - nQ J <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Q ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D 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. ❑ IL ❑ 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# JURISDICTION# AGENCY# FACILITY ID If It of TANKS at SITE <br /> 3 p / / d d <br /> CURRENT OCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE X WITH AREA CODE <br /> I ese <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINES SPUN FILED DATE FILED <br /> YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> 1 <br /> :j FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON 1 <br /> FO A(3-2-SS) <br /> �— DATA PROCESSING COPY `—' T <br />