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"t'iu•ii� lie <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SST�Fl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o `P <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY F-] I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION M <br /> 00 <br /> G Eo d v- <br /> ADDRESS N REST CROSS HE ✓&abNldcab ❑ PARTNERSHIP ❑ STATE AGENG( <br /> / / _ ❑ CORM70N ❑ LOCNAGENC( ❑ FEDERAL <br /> !/Yl.• ❑ nnmouAL ❑ COUN AGENC( <br /> CITY NAME o STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA Sa Cao 4 3 SQO <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSDR ✓Box if INDIAN EPA ID X '- ASI �. B o1 TANK'4 <br /> RESERVATION or ❑ ✓L4,— AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM HER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATIO & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D 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 ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> 0 INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.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. ElII- El III.El <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# AGENCY# FACILITY ID N M of TANKS at SITE <br /> 010 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> V� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT DE BUSINESS PLAIN FILED ❑ DAF FILED I <br /> � a3 , e/Q 3 YES NO <br /> E] <br /> PERMIT AMOUNT (/ SURCHARGE AMOUNT FEE CODE 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 j <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY �.I - <br />