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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w <br /> 9— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 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 q Z <br /> IC <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A/ C rV <br /> ADDRESS NEAREST CROSS STREET ✓Roe to Mute ❑ PARTNERSHIP D STATE AGEND CD <br /> ❑ GOAPDMTION ❑ LOUNT(CA <br /> CALAFNCI ❑ FEDEMbAGENb}' <br /> ❑ INDIVIDUAL GENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> �SCy CA q63 ZD -i n.dx <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 P4<ESSOR ✓Bax if INDIAN EPA ID # #of TANK's <br /> RESE <br /> ❑ I GAS STATION [:] 3 FARM 5 OTHER TRUSTVATION LANDS d ElAT THIS SITE a-- <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS VAME(LAST.MRSIT NE#WITH AREA GO E NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS Cl Box to Indicate ❑ PARTNERSHIP STATEAGENCY <br /> /� RN ❑ CDIVIDUAL ATION FI COUNTY-AGENCY El LOCAL AGENCY E3 <br /> -AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE ^� <br /> re?v&j <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 WNICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. luK 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# JURISDICTION If AGENCY# FACILITY ID# #of TA KS A7 SITE <br /> ELI = = I oU vo I o <br /> CUR ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3LC) <br /> FRUIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FL D <br /> YES [—] NO 2 <br /> CHECK# PERMIT AMOUNT SURCHAR EAMOUNT FEE CODE I RECEIPTM 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 ON/LY( <br /> FORMA(3-2-88) <br /> `ftw DATA PROCESSING COPY <br /> J <br />