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STATE OF CALIFORA WATER RESOURCES CONT BOARD e <br /> a <br /> T <br /> FORM A . UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE �' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . <br /> CC l,— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ©5 CHANGE OF INFORMATION ❑ 7 P ANENT CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACT SITE NUM CARE OF OGRESS INFORMATION <br /> y1 ry <br /> tTREET ✓ouloirdame ❑ PAIRNERSHIP ❑ SiATEAGENCY <br /> ADDRESS — ❑ "0NP0&AiION ❑ LOCAL AGENCY FEDEAALAGENLY16 TF ❑ INDIVIDUAL ❑ CWNTYAGENC/CITY NAME / D ZIP CODE ITE PH E#,WITH AR CODE <br /> CA <br /> If of TYPE OF BUSwEss: ❑2 DISTRIBUfOfl ❑ 4 PROCESSOfl RE EBox if INDIAN RVATION Gr ATTHISK'e <br /> 1 GAS STATION ❑ 3 FARM OTHER TRUSTLANDS ❑ ATTHISSITEEMERGENCY CONTACT PERSON (PRIMARY) CONTACT PERSON (SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NA E(LAST,FIRST) P N #WITH AREA CODE <br /> NIGHTS: NAME LAST, ST) PHONE WITH AREA NIGHTS'. ME(LAST.FIRST) P}10 E M WITH AREA CODE <br /> /T lq� d(' <br /> At VA <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARED A/D�DHESS INFORMATION <br /> 11 <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Ai <br /> [I CORPORATION El LOCAL-AGENCY FEDERA -AGENCY <br /> L`' ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY Njj STATE ZIP Copf PHO #,WITH AREA CODE <br /> � S <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME_ CARE OF DDRESS INFORMATION <br /> CLl <br /> MAILING or STREET ADORES ✓D�indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Y ❑ CORPORATION ❑ LOCAL-AGENCY 1:1F ERAL- GENCY <br /> 1` El INDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAME , ' STATE ZIP COA PHON WITH AREA CODE <br /> ,1 A � <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECKONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COrnNTY# JURISDICTION# AGENCY# FACILITY ID# #OI TANKS at SITE <br /> ff2tjILITY ID# APPLNAMEPHONE#WITH AREA CODE <br /> oPERMIT APPROVAL DATE ATE <br /> S TRACT# SUPERVISOR-DISTRICT CODE YES NC DATE F EDqq ERMIT AM�� SURCHA��MOUNT EIPT# 9 BLrY/�i <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 /> FORMA(3-2-86) <br /> DATA PROCESSING COPY / <br />