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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� o <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a - <br /> W <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 00 <br /> FACILITY/SREN TCA CARE OF ADDRESS INFORMATION <br /> r, 9-e_ T � us <br /> 0.S-Qd1 i n M i <br /> ADDRESS NEAREST CROSS STREET ✓Bmlo irdcale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CO O TION ❑ LOCALAGBICY ❑ FEOEEIULAGENCY <br /> O� O" Cl INONIOUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> __Fr_Ck CA 01 <br /> TYPE OF BUSINESS: F-1 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or #of TANK'S <br /> ❑ 1 GAS STATION [:]3 FARM HER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE F WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE F WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,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 N JURISDICTION If AGENCYN, FACILITY ID# N of TANKS at SITE <br /> 1 L� I U <br /> CURRENT LOCAL AGENCY FACILITY ID N ^ APPROVED BY HAM PHONE N WITH AREA CODE <br /> PERMIT NUMBER PER/MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED �j �1 <br /> 3 �� YES NO ❑ O 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMO FEE CODE RECEIPT BY: <br /> THIS11 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 (3-2-681 <br /> +� DATA PROCESSING COPY ala/ <br />