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STATE OF CALIFORNA WATER RESOURCES � <br /> CONTF�OL BOARD ;,�::• E�A�e <br /> FORM 'A'-,-. �P s <br /> UNDERGROUND STORAGE TANK PROGRAM w LL <br /> SITE K/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 ° o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1-FORN\P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> dev- <br /> ADDRESS NEAR T ROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> `� �❑f PIORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> •...Ir 2 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA �6e7 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR 'v/Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARMOTHER RESERVATION or p #of TANK's <br /> TRUST LANDS ❑ �./j,G AT THIS SITE 00 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHON7#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> , <br /> l dA <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S ,�E <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> _SS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> C 1 <br /> t � v/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> DDRESS <br /> v >SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111. ❑ <br /> VALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> l <br /> DATE <br /> I <br /> GENCY# FACILITY ID# #of TANKS at SITE <br /> I E 1 0 0 1 1 1 Tl I A-) 1 0 1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYAME PHONE#WITH AREA CODE <br /> �¢tL ylz q1 jr 5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O � C r� YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY; <br /> I . <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 /> FORMA(3-2-88) • <br /> 0 & PROCESSING COPY 000 <br />