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STATE OF CALIFORN« WATER RESOURCES CONTROt�OARD <br /> FORM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM t b' <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� to Z <br /> o. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °4r�ronn�n <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT Z 5 CHANGE OF INFORMATION <br /> ONE ITEM 2 INTERIM PERMIT0 T PERMANENTLY CLOSED SITE N <br /> 4 AMENDED PERMIT 06 TEMPORARY SITE CLOSURE 4 I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FA TY/SITE NAME N <br /> CARE OF ADDRESS INFORMATION N <br /> ADDRESS S <br /> ,/� NEAREST CROSS STREET ✓IIwro Mme¢ ❑ FAPINBIGHIP ❑ STATE AGENCY <br /> 5 /7 L ❑ #TION ❑ U44 AGR Y ❑ FEDEPX AGDO <br /> CITY NA!/E INDnDIAL ❑ �GNry.AGENGy <br /> MSTATE ZI CODE SITE PHONE N.WITH AREA CODE <br /> TYPEOF BU6INESS: p IBUTOB 4 PROCESSOR I/Box if INDIAN EPA IDA .3 <br /> El I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ - #of TANK'# <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAMELASTFIRST)IRST <br /> ( ) PHONE N 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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ClCOUNTY-AGENCYCIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME DARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box toinolcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 B AGENCY R FACILITY ID If If of TANKS H SITE <br /> uI 1 14 1 0 ER <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE k WITH AREA CODE <br /> i rnJT 7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO —7 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEECODE 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 ONLY. <br /> . I <br /> FORK-A(3-2-BS) <br /> 7W� �� DATA PROCESSING COPY �/ <br />