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STATE OF CALIFORNIA* WATER RESOURCES CONTROLIVOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM =" A, <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 141 COMPLETE THIS FORM FOR EACH FACILITY/SITE �"1eO0.=�' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMA LY CLOSED SITE F'J <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ct9 c" <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /7 <br /> ADDRESS / NEAREST CROSS STREET ✓BOK Io iMrale D LOCAL GEN ❑ FEDERAGENCY <br /> AGEN <br /> y I��yJ ❑ ON D COUNTY AGENCY ❑ FEDERAL <br /> el4)b er DrvIDUAI Cl LWNtt AGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 3' R3 <br /> TYPE OF _SS: ❑ 2 DISTRIBUTOR ❑ 4 PROC R ✓Box it INDIAN EPA ID # #of TANK's <br /> ' RESERVATION or 1:1 AT THIS SITE <br /> aASSTATION ❑3 FARM HER 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 /> 23 <br /> NIGHTS: NAME(LAST,FIRSYf PHONE#WITH AREA CO E NIGHTS: NAME(FAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME - CARE OFADDRESS INFORMATION <br /> MAILING or STREET ADDRESS n ✓Box to indicate D PARTNERSHIP D STATEAGENCY <br /> O C9i1P6RATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O/ G1I(DIVIDUAI ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME /�� CARE OF ADDRESS INFORMATION <br /> ^� <br /> MAILING or STREET ADDRESS ✓Box tolntllcate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> Cl INDIVIDUAL D 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: I. P r <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 N JURISDICTION N AGENCY# FACILITY ID p. #of TANKS at SITE <br /> EKE0 3 5 v ­ 00 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BYNAME _�' PHONE N WITH AREA CODE <br /> PERMIT NU __PERMPPAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOLCDE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE F`ILED Q�Z YES NO [ Q Z, a QCHECK# PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT# <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-SB) 0 `J\ <br /> DATA PROCESSING COPY <br />