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STATE OF CALIFORNIN WATER RESOURCES CONTROBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o z <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ry <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N <br /> co <br /> ADDRESS Pam c� NEAREST CROSS STREET ✓gy�W ❑ PARTNERSHIP ❑ SigiEAGENLY <br /> ' J ❑rCCIPiNCIAORATION ❑ C Ate,AGENCY <br /> AGENCY <br /> ❑ TATE AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> Ri W CA 2 5 - 51 <br /> TYPE OF BUSINESS: L]2 DISTRIBUTOR ❑ 4 PRO SSOR 7B0.4 INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE AT THIS STE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS:' NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(IAST,FIRST) 4cdPHONE N WITH AREA CODE <br /> S - 1S/ ry b <br /> NIGHTS: NAME(LAST F ST HONE#WITH AREA CODE NIGHTS. NAME(LAST FI STI PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDER 5INFORMATION <br /> MAILING or STREET ADDRESS ✓B Indlc� 0 PARTNERSHIP Cl STATE-AGENCY <br /> P0 INDIIVIDUALORPORATION 0 COUNT LOCAL-AGENCY El <br /> AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME I ^ <�� CARE OF ADDRESS INFORMATION <br /> f/ <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATEAGENCY❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. 1. ❑ (BI.❑ <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 If AGENCY# FACILITY 10# If of TANKS B1 SITE <br /> to ( doocg <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> I <br /> PERMITkNUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATICENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> YES � NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE 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(3-2-88) <br /> DATA PROCESSING COPY <br />