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/Oval, <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FAC LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PER IENTLY CLOSEDSITE F� <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) A <br /> v <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ` NEAREST CROSS STREET F✓I B"OF Io�i�ate ❑ PARNERSHIP ❑ STATE AGENCY <br /> •./^ , L i N Ne K y=^�0AATION ❑ LOCALAGENCY 0 FEDERAL- <br /> AGENCY <br /> IA INDIVIDUAL ❑ COUNIYAGENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA 10 a <br /> ESEATIONE] 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS 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(LAST,FIRST) ,LP)IONE N WITH AREA CODE <br /> COC c5 IF IL V/_ <br /> NIGHTS'. NAME(LAST, RST) PHONE N WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME AA CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �evv'f j4l <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU 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. 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# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> I / 17151 101010111 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> oc 59 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 2 ' YES NO <br /> CHECK# PERMIT AfAOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> w,t'S <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 ONL' <br /> FORM A(3-2-81 ,DATA <br /> DATA PROCESSING COPY <br />