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STATE OF CALIFORNI)' WATER RESOURCESCONTRdtTbOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE �FILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F LITY/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 d2 Z <br /> I. FACILITY/SITE IN ORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME / ,/ / CARE OF ADDRESS INFORMATION <br /> ADDRESS > y,,/ NEAREST CROSS STREET ✓BmbirAreN ❑ PNtt4E15HIP ❑ STATE AGENCY <br /> ❑ COW010noN ❑ uxu AGENCY ❑ Faxm_vFE <br /> / /• Q GLG(,�/Y�e ❑ I"IDUAL ❑ COUNTY AGENCY <br /> CITY NAME Ti/ STATE CZI�,COQ�_ SITE p�WIT AREA CODE <br /> A <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓B0s fl INDIAN EPA ID 4 ✓\S G/ s <br /> RESERVATION or F of TANMa <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT TNIS 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 Al WITH AREA CODE NIGHTS: NAME(LAST.FIRST) 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 ✓Bas to mol,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHEf7(ONE(1)BOX INDICATING WNICN 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 41 JURISDICTION R AGENCY N FACILITY IDR R of TANKS at SITE <br /> EU = = I I I i`A'7,,9T7M <br /> CURRENT LOCAL AGENCY ID N APPROVED BY NAME PHONE F WITH AREA CODE <br /> YF <br /> V ' /' / <br /> PERMIT NUMBER PERMIT APPROVAL DATE #mE <br /> IT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT COESS PLAN FILED DATE FILEDP7 <br /> Z YES NO1 -7 O�J� <br /> CHECK F / PERMIT AMOUNT SURCHARGE AMOUNT RECEIPT M 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 0 <br /> iCRM A(3-2-88) <br /> �� �I <br />