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STATE OF CALIFORI9 WATER RESOURCES CONTROL BOARD <br /> f <br /> FORM `A': ' ` <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ tuN, ❑ PARTNERSHIP ❑ STATE AGENCY <br /> CORPORATION ❑ LOX AGENCY ❑ FEDERAL AGENCY <br /> 1 ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP ODE SI E PHONE N,WITH AREA CODE <br /> L CA 53 <br /> TYPE OF BUSINESS. ❑ 2 DIST IB OR ❑ 4 P ESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or Mof TANK'S /t <br /> ❑ I GASSTATION ❑ 3 FARM OTHER TRUST LANDS 1:1 /✓1/ ���! AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE AVS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) ,\ PHONE B WITH AREA COD NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DRES - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ildlYrHA ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &A DRESS - (MUST BE COMPLETED) <br /> NAME CA OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS V'R..to,Yd,c.He ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATIO AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ill. ❑ <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 R JURISDICTION M AGENCY R FACILITY ID R R of TANKS at SITE <br /> [Na 10 10 111I O 10 1(70 <br /> CURRIEMLLOCAL AGENCY FACILITY ID k APPROVED BY NAME %AD PHONE k WITH AREA CODE <br /> 00 ct <br /> PERMIT NUMBER 'A/V• PERMIT APPROVAL DATE If PERMIT�E/XPIPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 p�3AYES NO El <br /> CHECK X PERMIT AMOUNT SURCHA GE AMO NT FEE CODE RECEIPT X BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />