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STATE OF CALIFOR" WATER RESOURCES CONTRZL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> T COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 197 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> oob S f cc <br /> ADDRESS NEAREST CRZgx�kOSS STREET ✓Mmmmnle 0 PARfNa MIP 0 STAT AGENCY <br /> /a D N , L A� OB c�ew.nM ❑ LOCK AGENa ❑ FmBiu ACENCT <br /> E-=,FM 0Iawxn.AGEllg <br /> CITY NAME STATE JIP CODE SITE PHONE N,WITH AREA CODE <br /> CA / <br /> TYPE OF BUSINESS: ❑ 2 DIS IBUTOR ❑ 4 PROCESSORBoz d INDIAN EPA ID N <br /> RE✓SERVATION or M of TANK4 <br /> ❑ I GAS STATION FARM ❑ 5 OTHER TRUST LANDS 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 A WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILINGor STREETADDRESS */Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY/ 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME ^ ��k-* STATE ZIPCODE5� PHONE ITCODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or ST ET 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)BOK INDICATING WHICH ABOVE ADORRBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. Ill. ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY M FACILITY ID R S of TANKS At SITE <br /> CURRE (51.AGENCY FAAPPROVED BY NAME _ PRONE 1 WITH AREA CODE <br /> D Cr�`-J <br /> PERMIT NUMBER PERMIT APPROVAL DATE P►•:MIT EXPIRATION DATE <br /> L <br /> CENSUS TRACT0 SUPERVIS 1I-5TRI�DE BUSINESS PLAN❑FILED DATE FIEO"l\3 YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ SY: <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 ONLY. <br /> FORM A(3-2-88)q <br /> Q-lQ� S L <br />