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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " m" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE `'•iron" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> F NAMEC ARE OF ADDRESS INFORMATION <br /> ADORE NEAREST CROSS STREET ✓ftbbdnb 0 PAWNERSIP ❑ STATE AGEIKY <br /> C{ 0 COWOMTION 0 LOQUAGENLT 0 FE)SIM-AGENCY <br /> 0 INDMDIAL 0 UxlflY AGEND <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA -2a 4 6 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN EPA ID N <br /> RESE❑ of TANKs <br /> 1 GAS STATION ❑ 3 FARM 11rTHER TRUSTVLANDS Or ❑ • "L/ '��� AT THIS SITE cpl <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( ST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> i G <br /> NIGHTS: AME fLAST.FIRST) OPHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 WHICN ABOVE ADDRESS SHOULD B USED FOR OWN LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE URY,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 E JURISDICTION R AGENCY E FACILITY IDA` R of TANKS H SITE <br /> MI E= Ob / S DOD <br /> CURRENT LPGIIL IIGENCT�CILITT ID N APPROVED BY NAME PHONE A WITH AREA CODE <br /> J\ nW-I^I o D C _ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-0IST111CT CODE BUSINESS KAN FILED DATE FIUEP <br /> V I a 3 . g 3 a YES � NO <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM •B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLIC-) <br /> ORM A(3-2-88) <br /> uo <br /> ��✓� ��� <br />