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STATE OF CALIFORNIP WATER RESOURCES CONTROBOARD <br /> I 1 , <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> �—/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P` CLOSED SITE <br /> ONE ITEM ❑2INTERIM PERMIT ❑1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (� Z <br /> I. FACILITY/SITE INFORMATION &/ADDRESS -'(MUST BE COMPLETED) <br /> FACILITYYSITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS �/ �/ NEAREST CROSS STREET 13Bm x 11PAFG AT ❑ sTATE-AG NC! <br /> // <br /> ,1'Nmf; 13 MAIM 11 COUNTY AGENCY <br /> CITY NAME 104 <br /> _ - STATCA ZIPCODE`7 SITE =p,WITH ARMC <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR N PROCESSOR ✓Box B I IAIAN EPA 10 N J <br /> ONOWof N S <br /> ❑ I GAS STATION ❑3 FARM ❑ 50THEfl TRUSTYLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA COOS <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓Box to imcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE p,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 inaicale ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,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. ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION B AGENCY Y FACILITY ID N S of TANKS At SITE " <br /> �/ 14 171 S 10 z�-1 - <br /> CURRENT LOCAL AGENCY FAgUM M P APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENB�T� / BUPERVIB _fl a CODE BUSINESSPLAN <br /> NO ❑ DATE FILED <br /> CHECK# PERMIT AMOUNT C! 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 ONLY. <br /> FORM A(3-2-e8) �, <br />