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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE E TANK PROGRAM � Ao <br /> � AoFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ci COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE sy <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION �W�n <br /> V• <br /> ADDRESS NEAREST CROSS STREET ✓NmkitliwR ❑ PARTNERSIP ❑ NATE AGENCY <br /> 3 E ❑ WEPORANON ❑ LOCALAGENLY Cl ROERALAGBNY,Y <br /> ❑ INDMDUAL ❑ WUNTYAGENCI <br /> CITY NAME ^ STATE ZIP DE SITE PHONE if,WITH AREA CODE <br /> V\ CA 7, ao5 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ I GASSTATION3FARM OTHER RESERVATION or �,� /{�� p #of TANK# <br /> ❑ TRUST LANDS ❑ w �" ' ��� AT THIS SITE IMIOW <br /> EMERGENCY CONTACT PERSON PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME("ST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓80x W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST COMPLETED) <br /> NAME CAR F ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box t "C'to ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORP TION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDU ❑ COUNTY-AGENCY <br /> CITY NAME STATE IP 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 A BILLING: I. ❑ II. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# AGENCY R FACILITY ID# X of TANKS at SITE <br /> � Oa � So 0060 <br /> CURB T LOCAL AGENCY FAGIL TY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER /V/l1\_�jf PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ON DE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILJ <br /> 4 YES NO � / �O •, ` <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> 11 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THISIS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 FORMA(3-2-!!0) <br /> ,Uv1 2 0 <br /> `i DATA PROCESSING COPY <br />