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STATE OF CALIFORNIP WATER RESOURCES CONTROOOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONw <br /> ` COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT E<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE IbI71 <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> W <br /> FACI / ITE NAME /I CARE OF fOGRESS INFORMATION <br /> ADDRESS I ,� AI E T CROSS STREET ✓CORPORATION <br /> RATIO ❑ PARTNERSHIP ❑ FEDERAL <br /> AGENCY <br /> /yv/L '(`/I^C), ❑ CORPORATION ❑ PLOCAL ARTNE SHIP ❑ FEDEEAGENCY Y <br /> ❑.INDIVIDUAL ❑ COUNIYAGEN6 <br /> CITY STATE ZIP CODE SITE PH NE N,WIT AREA CODE <br /> CA 7i <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p I <br /> ❑ Y�t ❑ TRUSTTVLANDS or ❑ A #DI TANK'S /�/ti <br /> 1 GAS STATION 3FARM SOTHER AT THIS SITE (,/�(./ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: PIAME(LAST,FIRST) PHONE# DER AREA CODE DAYS: NA E LAST.FIRST) PHON #WITH AREA CODE <br /> � IA A <br /> NIGHTS'. NAME(LAST,FIRST) PHOZ#WITH AREA CODE NIGHTS\P ME(LAST,FIRST) PLO #WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DDRESS - (MUST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> s LA <br /> MAILING or ST ET ADDRESS ✓Box to indlcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILING or STREIET ADDRESS ✓Box toiodicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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: LW it. ❑ 111.❑ <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 If AGENCY# FACILITY ID# #of TANKS at SITE <br /> b ?- 1 1010 10 <br /> CURRENT T�ENCY FACILITY APPROVED BY NAMEPHONE#WITH AREA CODE <br /> PERMIT NUMBER SS Z PERMIT APPROVAL DATE PERMIT EXPI ATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISE) -DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> YES NO <br /> CHEC PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT# 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 /> 0 DATA PROCESSING COPY <br />