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STATE OF CALIFORPf1 WATER RESOURCES CONTROL BOARD <br /> zE <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION `9r,fioaH / <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT E] Y AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> N ,,Z <br /> ADDRESS CARE OF ADDRESS INFORMATION <br /> Y`' /C <br /> NEAREST CROSS STREET ✓Soo to w,,e ❑ PARTNERS41P ❑ STATE AGENCY <br /> LGayy�/� ❑ CORPORATION ❑ LOGLAGENCY Cl FEOEMLAGENCY <br /> CITU NAME ❑ INolvic AL Cl COUNTY AGENCY <br /> ,,-57b C1C C� STATE ZIPCODE SITE PHONE Y,WITH AREA CODE <br /> TYPE OF BUSINESS l- CA <br /> Lj 2 DISTRIBUTOR [:] q PROCESSOR ✓Box it INDIAN EPA ID Y <br /> I GASSTATION ❑ 3 FARMTHER RESERVATION or ❑ Y of TANK'Y <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE n WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to iodi,ate ❑ PARTNERSHIP <br /> ❑❑ CORPORATION ❑ LOCAL-AGENCY STATE-AGENCY <br /> INDIVIDUAL FEDERAL-AGENCY <br /> CITY NAME ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicale ❑ PARTNERSHIP <br /> ❑ CORPORATION LlLOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME El INDIVIDUAL ElCOUNTY- FEDERALAGENCYAGENCY <br /> STATE 21P CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION If AGETNCY p FACILITY ID p <br /> �J If of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME <br /> / 3U PHONE N WITH AREA CODE <br /> PERMIT NUMBER i PERMIT APPROVAL DATE <br /> PERMIT EKPIRATION DATE <br /> LOCATION CODE CENSUS TRACT A, SUPERVISOR-DISTRICT CODE <br /> � BUSINESS PLAN FILED DATE FILF� <br /> 3, YES <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE PECEIpTAf NO �r <br /> BY: <br /> THIS FORM HOST BE ACCOMPANIED BY AT <br /> FORMA(3-2-88) LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> V\ DATA PROCESSING COPY <br />