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STATE OF CALIFORNIV WATER RESOURCES CONTROBOARD E <br /> �Z Mm <br /> w <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) l' <br /> OD <br /> FACILI / TE NAME TT CARE OF ADDRESS INFORMATION <br /> A V <br /> ADORESSc NEAREST CROSS STREET ✓BY,.la irdiak D PARTNERSHIP D STATE AGENCY <br /> /,J q7 TOD INDIVIDOATIDN D COUNTY AGENCY <br /> LOCALAGENCY D FEDEAAbAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> C <br /> CA 5 3aZ� <br /> TYPE OF BUSINESS ❑ DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATIONar #of TANK'# <br /> ❑ I GASSTATION 3FARM E] 5OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(FAST FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDR S ✓Box taindicate ❑ PARTNERSHIP D STATE-AGENCY <br /> /[�/"`/�. ❑ C}�RPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> i U�TNDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> SCC <br /> GA- 3 <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> D 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: L ❑ I. ❑ 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 Is #of TANKS at SITE <br /> 1 1 11-1101015 1 1 1 1 C;2 <br /> CURRENT LOCAL AGENCY FAC ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER 'r[,� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK <br /> 0 CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES ❑ NO ❑ & - 9L <br /> # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 /> WI DATA PROCESSING COPY <br />