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sw <br /> STATE OF CALIFORNIA WATER RESCfURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V <br /> W <br /> z ¢ o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FAPL <br /> ITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT 713 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY ITE ME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box Ioindua ❑ PARTNE HIP ❑ STATE AGENCY <br /> El CORPORATION -AGENCY ❑ FEDERAL-AGENCY Q <br /> - ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME , STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA `1 Ste' <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PRO,C ✓Box if INDIAN EPA ID # #of TANK's <br /> ❑ GAS STATION 3 FARM THER RESERVATION or ❑ AT THIS SITE <br /> ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA {LAST,FkRST) PHONE N WITH AREA CODE DAYS', NAME{LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS; }NAME(LAST,FIRST M P p 3 WITH AREA CODE NIGHTS: NAME( FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET DRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 1- STATE ZIP CODE P NE#,WITH AREA CODE - <br /> �< C �9- f3 <br /> III. TANK OWNER INFQ MATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Rox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Eul I I I �] El T:l I(!� b I / I�/ ITE] L Q b I c 1 a-H <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> r� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CORE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> l7 1 Y -I YES ❑ NO ❑ eg <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOU T FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM `B"APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> r" DATA PROCESSING COPY <br />