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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s`A;' "^ <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM p X" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �° too <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��.o,e`N <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'J <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRE f NEAREST CROSS STREET ✓BN= ❑ PARTNEBBIIF E3SIAIE-CENQ <br /> 4' y/n e L ❑ KK! ❑ LOMAGDILY ❑ FEDERk AGEN <br /> Nom DWL ❑ WUNIY AGENCY <br /> CNV NAME / STATE ZIP CODES�® SITE PHONE p,WITH AREA CODE <br /> A <br /> TYPE OF BUSINESS. ❑ 2 DIST ❑ 4 PROCESSOfl ✓Boz if INDIAN EPA ID N <br /> RESEVATION❑ 1 GAS STATION FARM ❑ 50THER TRUST LANDS OF ❑ GL Dom— 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Bos noicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S g , <br /> MAILING o,STREET ADDRESS ✓B to indicate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> ❑ ORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ III. <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 B JURISDICTION R AGENCY M FACILITY ID If R of TANKS at SITE <br /> 3y / ao0 / <br /> CURRENT LOCAL AGENCjY F1TY1'Dl.N�? APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER <br /> In <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTa SUPERVISOR-DISTRICT CODE BUSINESS ❑FILED NG ❑ DATE FILED /3 <br /> 03 <br /> YES <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 6BY: <br /> c — <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 ONL� <br /> FORM A f3-2-88) <br /> DATA PROCESSING COPY <br />