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STATE OF CALIFORNIA* WATER RESOURCES CONTROL BOARD ( i <br /> l <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM n _ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION .° r c <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ 7 PERMA Y CLOSED SITE N <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT � 5 CHANGE Of INFORMATION aj <br /> MARK ONLY ❑ ❑ s TEMPORARY SITE CLOSURE Ln <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT (� <br /> cm <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (/MUST BE COMPDDLETEDRESS RMAnoN <br /> FACILITY/SITE NAME r /1/k'}-/V <br /> E OF Ix Hy e ✓Box to sitliNle El PARTNERSHIP ❑ STATE AGEND <br /> NEAREST CROSS STREET El CORPORATION ❑ .00AL AGENCY ❑ FEDERAL AGENCY <br /> ADDRESSV6/ /e/. e El INDIVIDUAL [:I COUNTY AGENCY <br /> /� STATE ZIP CODE SI HE PHONE d,WITH AREADE <br /> CITY NAME CA <br /> EPA ID # #Ot TANK'S �} <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 P CESSOR /Box it INDIANRESERVATION or AT THIS SITE <br /> 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS El <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME LAST,FIRST) PHONE N WITH AREA COOS DAYS'. NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> r <br /> PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIR ST) PHONE#WITH AREA OODE NIGHTS. NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE CCARE OFoOMPLLETEoD) <br /> NAME <br /> ✓Box mintlicate [I PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY.AGENCPHONE p,WITH AREA CODE <br /> STATE ZIP CODE <br /> GIN NAME <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)CARE OF <br /> SS <br /> NAME C <br /> J ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNtt-AGENCY <br /> STATE ZIP CODE PHONE H WITH AREA CODE <br /> CIN NAME <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: 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 /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> #of TANKS at SITE <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# 90EDE <br /> APPROVED BY NAME PHONE#WITX AREA <br /> CURRENT LOCAL AGACILITY ID p <br /> PERMIT NUMBER <br /> 4/ PERM APPROVAL DATE PERMIT EXPIRATION DATE <br /> DE CENSUS T CT# SUPERVISOR- CODE BUSINESS PLAN FILED DATE FILED <br /> LOCATION <br /> VES O <br /> CHECK# PERMIT AMOUNT SURCHARGEAM UNT FEE CODE ❑RECEIPT# ❑ BY: <br /> v <br /> IS FORM MUST BE ACCOMPANIED BY AT LEAS f1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S)E <br /> SS THIS IS A CHANGE OF SITE INFORMATION ON <br /> 5 yy <br /> ORM A(3-2-Re) DATA PROCESSING COPY <br />