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STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION tZo <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 FERMI CLOSED SITE F'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE fl <br /> W <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ,CD <br /> r" FACILITY/SITE `y7 ✓♦ - CARE OP DDRESS INFORMATION v 1 <br /> ADDRE tJ NEAREST CROSS STREET ✓Em to irAiute ❑ PAgiNEBS4IP ❑ STATE AGENCY <br /> �1 �I ❑ COAPOMTION ❑ IOCALAGENCY EHAL AG Cy <br /> ❑ INDNIDUAL ❑ COUNttAGENCY IA <br /> CITY NAME e STATE ZIP CO SITE P ONE p,WITH AR CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 ROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAB STATION ❑ 3 FARM �5 POTRER RESERVATION or ❑ �/� AT THIS SITE O <br /> TRUST LANDS N Y'� AT THIS SITE v <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) P ONE If WITH AREA CODE <br /> fh' q - S <br /> NIG TS: NAME(LAST.FIRST) PHONE#WITH AREA ODE NIGHT9. NAME(LAST,FIRST) pNE#WITH AREA CODE <br /> II. PROPERTY 6WNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE O ADDRESS INFORMATION <br /> S � a <br /> MAILIN rSTRE ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ,pl / A ❑ CORPORATION ❑ LOCAL-AGENCY F DER NCV <br /> L V V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ! STA E Z(�IP C � PHONE ITH AREA CODE <br /> OL / <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 A80VE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. 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 /> q s- o <br /> CURRENT LOCAL AGENCY FACILITY ID# APPR V BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION`CODE CENS�TRVP34 SUPERVIS - ISTRICT CODE BUSINES YES NFILED NO "DATE FIL U� <br /> CME # PERR�MIT AMOOOyyUNTT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: <br /> IV� THISFORM MUST BE ACCOMPANIED BYATLEAST(I)OR MORETANKPERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OFSITE INFORMATION ONLY. <br /> ` J FORM A(3-2-68) <br /> V i DATA PROCESSING COPY <br />