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STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•�^-"-'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 0i0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> We— <br /> ADDRESS NEAREST CROSS STREET ✓B INi oiw ❑ PARMERRIIP ❑ STATE AGDO <br /> ❑ ION T 13 LOCAL-AGENCY 11 RGERk AGENCI <br /> NDMDUaL ❑ MUNTY.AGENDY <br /> CITY NAME STATE ZIP CODESITE PHONE 9 WITH AREA CODE <br /> Lodi CAL <br /> TYPE OF BUSINESS'. ❑ y RIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> A of TANK'N <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS oATION r ❑ /C— AT THIS SITE U <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 /> F lri"ds s A <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S S <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS j` ✓Box tomc,SW. /- ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CQAPeRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME mlSTATE ZIP CODE PHONE N,WITH AREA CODE <br /> S f� � 5,4- <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ^ ❑ TION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> /T NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE JZIP CODE PHONE N.WITH AREA CODE <br /> S <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. ❑ If. ❑ <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 R AGENCY N FACILITY ID R If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBERI,K_/'J/— PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Or 3 a3 3 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 /> ! FORM A(3-2-SB) \ <br /> DATA PROCESSING COPY -� <br />