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STATE OF CALIFORNfA WATER RESOURCES CONTROL BOARD s` ' <br /> _ s <br /> FORM A': UNDERGROUND STORAGE TANK PROGRAM V <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMI7 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [—]6 TEMPORARY SITE CLOSURE PO <br /> 1. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) W <br /> FACRUYI9H£NAME/ <br /> tCAREF ADDRESS INFORMATION ADDRESS , T CROSS STREET ✓BNbidM ❑ PAAREI6IIP ❑ 5fATEAGEtX,YD COEOMTI011 D LX&L ,N,Y ❑ R#MLAGFNLY❑ RCMDAL ❑ COM ----CITY NAME ZIP CODE SITE PHONE N,WITH AREA CODE <br /> A <br /> TYPE OF 8USINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Boz if INDIAN EPA ID N <br /> I GAS STATION ❑3 FARM ❑5 OTHER TRUSTYLANDS or Is of TANK's❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,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 /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> Cl INDIVIDUAL D 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 w STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. ❑ II. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION# AGENCY# FACILITY IDB B of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE S WITH AREA CODE <br /> 7l / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> i <br /> LOCATION CODE CENSUS TRACT P SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D 3. YES ❑ NO ❑ y <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCO ANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY./^ <br /> FORMA(3-2-BS) ` <br /> DATA PROCESSING COPY a� /\\ <br />