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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> iE" lAe <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> l .owx_'^^ y <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PER TLV CLOSED SITE 7j <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / •O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CA <br /> FACT SITE NPM CARE OF ADDRESS INFORMATION <br /> W V7 <br /> ADDRESS NEA EST CROSS STREEJ ✓&Al)Mole ❑ RURNEASHP ❑ STATE AGENLY <br /> '0 /V./�I ❑ CORPORATION ❑ U)MAGBIp 0 FEGEAPL AGENO, <br /> ❑ IwNto AL D .....AGEN.. <br /> CITY NAME /"t/ C4,,., STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> .0CA !5 a d <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> ❑ I GA55TATION ❑3FARM OTHEfl TRUST LANDS or ❑ NoI TANKY <br /> AT THIS SITE <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 <br /> 'W'T WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & DDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUS BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indmale D PARTNERSHIP 0 STATE AGENCY <br /> CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> INDIVIDUAL D COUNTYAGENCY <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 N IFICATION AND BILLING: I. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B T OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY00 FACILITY ID N N of TANKS at SITE <br /> ® � I d 011 E= Odd <br /> CURRENT LOCAL AGE CY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> Lf <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCDE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIED <br /> YES E] NO E] 3/61 <br /> CHECK N <br /> M§Mft AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAAT(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> q <br /> FORM�(3-2-8B) <br /> � <br /> "b x <br /> �JiT,,*v'1 DATA PROCESSING COPY <br />