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STATE OF CALIFORNM WATER RESOURCES CONTROL OARD 1 <br /> FORM 'A': P <br /> : .,;.. <br /> UNDERGROUND STORAGE TANK PROGRAM u _ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE `o ,P ata <br /> MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION cq<, <br /> ONE ITEM ❑ 7 PERMgNENiLV�CLOSEOSITEfV <br /> 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME W <br /> 5C_2­ CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boxbrdiute ❑ PAf7N815HIP ❑ STATEAGENCY <br /> CITY NAME <br /> 0Z El NDRPMATION 12 El �n E14M' ClFEOERgL-AGENCY <br /> Lo t2 i STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> 1 GAS STATION 3 FARM 5 OTHER TRUSRESET LANDS VATION or ❑ #of TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCYCONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 ✓80x to indicate ❑ PARTNERSHIP ❑ STATEAGENCYCl ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE b,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <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 If,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. ❑ 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 M #of TANKS BI SITE <br /> m F� I I <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> fi <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESSPSN FILED NO ❑ Ela <br /> G2 ZCHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM V APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />^� FORM A(3-2-88) <br /> L ) �O \, CQ Now DATA PROCESSING COPY sp `J <br />