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STATE OF CALIFORNI90 WATER RESOURCES CONTROLBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION ° o <br /> 14 COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-a <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> O <br /> FACILI /SITE NAME n CARE OF ADDRESS INFORMATION <br /> K L <br /> ADDRESS ^ NEAREST CROSS STREET ✓Box to MM ❑ PARTNERSHIP ❑ STATE AGENCY <br /> vim <br /> Nom, ❑ fpAPORATION ❑ MUM <br /> U AGENCY ❑ FEBERAL AGENL7' <br /> C7°U d��x V ,AK. yIN01V10EAL ❑ LOCAL AGGENCY <br /> CITY NAME STATE ZIP CODE TEP N T AREA CODE <br /> 65c O CA a D aL�/ �;15z <br /> TYPE OF BUSINESS: ❑p TRIBUTOR ❑ d PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or - #of TANK'S <br /> ❑ 1 GAS STATION a3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH'Al CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(ITAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME & CARE OF ADDRESS INFORMATION <br /> IU <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 p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toiodicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <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: I. ❑ I. ❑ If. ❑ <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 R AGENCY M FACILITY ID# N of TANKS at SITE <br /> 4oi ,6 <br /> CURRENT LQGAIAGINCYFACILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER I/']U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> E CENSUSTRACTIN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 5,a3 _?a YES � NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:�t <br /> 1 <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(3-2-88) <br /> DATA PROCESSING COPY 0 <br />