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STATE OF CALIFORNIIIT WATER RESOURCES CONTROL BOARD "`'•°"*+ ?' <br /> FORM 'A': ; <br /> UNDERGROUND STORAGE TANK PROGRAM s ;i," <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : a 1 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL I-a <br /> ONE ITEM E]2INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE __4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) Cb <br /> CTI <br /> FACILITY/SITE NAME `'Y a/'AT CRE OF ADDRESS INFORMATION <br /> tin �T,/ <br /> ADDRESS ,l/� /p/� NEAREST CROSS STREET ✓Bmbhk* ❑ PANTNERSHP ❑ STATE AGENCY <br /> A1 W It- COBPoMMN LBGL.AGENCY O FFBENAl#GENLY <br /> ❑ MGMBUAL ❑ CNITY-AUNLY <br /> CITY NAME STATE ZIP CODE SITEPHON K�WITfUARR ACODE <br /> S /fl✓M (�y3 <br /> ZZ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 ESSOR ✓B if INDIAN EPA ID q of <br /> ❑ I GAS STATION ❑3 FARM 5 OTHER TgLISTYLANDS or ❑ AT THOfTIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> OAY NAME(LAST,FIRST( PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL.AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCV <br /> CITY NAME STATE ZIP CODE PHONE At,WITH AREA CODE <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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. ❑ II. ❑ 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 a JURISDICTION# AGENCY R FACILITY ID R a of TANKS at SITE <br /> 0101 1 L10103 <br /> CURRENT LOCAL AGENCY FACILITY 10 a APPROVED BY NAME PHONE R WITH AREA CODE <br /> �N D <br /> PERMIT NUMBER P RMIT APPROVAL DATE PERMIT EXPIRATION DATE C <br /> LOCATION CODE CENSUS TRACT# 8UPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED <br /> �� 90 � YES � NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT# BY: <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> IpRM A(3-2-88I <br />