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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> WP: sA <br /> FORM A: �- , J <br /> UNDERGROUND STORAGE TANK PROGRAM =`� '-m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq pORN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Ile i ak <br /> ADDRESS NEAREST CROSS STREET A�CRATIOh <br /> ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p IBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> 5 OTHER RESERVATION or ❑ /�- JAT THIS SITE / <br /> ❑ 1 GAS STATION 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST))-�- PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR ` PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME ^t- <br /> IQ <br /> MAILING or STREETDDr7 i ` ✓Box to icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ C ORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> SA0.9 y <br /> MAILING or STREET ADDRESS ✓Boxindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ o,x ,ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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. II. ❑ 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 /> S�COUNTYY#�� JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> I l oZ <br /> f PHONE#WITH AREA CODE <br /> ` CURRENT LOCAL AGENCY FACILITY I� APPROVED BY NAME <br /> O� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 3 3 YES ❑ NO ❑ (j0 <br /> BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# A <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) J <br /> DATA PROCESSING COPY <br />