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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ / 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 3 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> iI /((C uiv/, I <br /> ADDRESS ry NEAREST CROSS STREET ✓Bw lo,i c, Cl FARfNEB$RIP ❑ STATE AGENCY <br /> 3 6 ,S ✓ac�lue ❑ coINIAMILAI w ❑ LOCAL AGENCY ❑ FEOBwI-ncwcr <br /> ❑ CORP u ❑ aCALAGEAGENCY <br /> CITY NA E STATE ZIP CODE SITE PHONE a.WITH AREA CODE <br /> AL, eecE <br /> CA S 336 <br /> TYPE OF BUSINESS ❑ ISTRIBUTOR oxif'PROCESSOR ✓BINDIAN EPA ID a aof TANK'S <br /> ESE <br /> ❑ I GASSTATION 3 FARM ❑ 5OTHER TRUSTYATION LANDS or ❑ AT THIS SITED <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> 1 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA / CARE OF ADDRESS INFORMATION <br /> Ll S Z <br /> MAILING or STREET ADDRESS ✓Box tc indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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. IL ❑ IIL❑ <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 a JURISDICTION X AGENCY a FACILITY ID a If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IO a APPROVED BY NAME PHONE a WITH AREA CODE <br /> 1-31 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINEB;P SN❑ FILED NO ❑ DATEjI D tA <br /> CHECKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# (/� BY: <br /> WTHIS 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) <br /> DATA PROCESSING COPY <br />