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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "` • � '"F <br /> m. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM - ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 2 <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE a�,.a ;. 10 <br /> MARK ONLY ❑ 1 NEW PERMIT Ej 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTI Y rl QqEDSITE IV <br /> ONE ITEM 2 INTERIM PERMIT ED4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ` <br /> C� 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 0 <br /> ADDRESS _ qRESERVATION <br /> NEAREST CROSS STREET ✓Boe — ❑ PWMMF ❑ STAIEAGENLY <br /> �nA ❑ MO flON ❑ LGCALa ENCr ❑ EEWLAGOO <br /> C�GY n iNGmowt ❑ cauNnAGENcT <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> / o CA 5 <br /> TYPE OF BUSINESS <br /> BUTOR /PROCESSOR BoxEPA ID p <br /> 1 GAS STATION E�r3 FARM 5 OT <br /> #M TANK'# O <br /> �/ —f} AT TNIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 5-4 SG[�•�� � <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS �C�C/ILGLT ✓SOz icaie ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S+ T �_ ❑ RPORATION 1:1LOCAL-AGENCY ❑ FEDERAL-AGENCY j <br /> V INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 172,qnknu o 9s3 3b 2v? s -�so3_ <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ 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: I. ❑ 11. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS M SITE <br /> CU ENT AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATO CODE CENSUSTRR CTO SUPERVISOR-DISTRICT CODE BUSINES,PSN❑FILED NO ❑ DATE FILED <br /> 39-C9 1 <br /> CHECKS PERMITAMOUNT — SURCHARGE AMOUNT FEE CODE RECEIPT# BY:1 073 <br /> �LV <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 ONL� <br /> FOR/(3-?-BY) <br /> Z "L DATA PROCESSING COPY <br />