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STATE OF CALIFORNIA WATER RESOURCES CONTROLB ARD \e <br /> FORM `A': W <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEro ��'� ate' <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM / PERMANENTLY CLOSED SITE IV <br /> 2 INTERIM PERMIT gAMENDED PERMIT ED 6 TEMPORARY SITE CLOSURE .Ori <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 4m <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> NEARES/TCROSS STREET I/R,to iM¢ale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 2 Q p ❑ CORPORATION ❑ LGCALAGENq ❑ FEDERAL- <br /> AGENCY <br /> CITU NAME Op— ❑ INRIND DAL ❑ COUNTY AGENCY <br /> STATE ZIP CODE�J SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS CA ^' <br /> L_j2 DISTRIBUTOR q PROCESSOR ✓Box if INDIAN EPA 10 # <br /> 1 GAS STATION 0 3 FARM 5 OTHER RESERVATION orTRUST LANDS AT THIS SITE <br /> ❑ #of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS. NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indlc.Ie ❑ PARTNERSHIP <br /> ❑ CORPORATION 11LOCAL-AGENCY <br /> STATE-AGENCY <br /> CITY NAME El INDIVIDUAL 11COUNTY- FEDERAL AGENCY <br /> AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box k,Hdicale �� , <br /> SHIP El❑ CORPORATION GENCY STATE-AGENCY❑ CORPORAT GENNCY FEDERAL-AGENCYSTATE ZIP CPHONE 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: 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If <br /> #o/TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY\ APPROVED BY NAME <br /> UPHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS TR CT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED <br /> � �• YES NOE] <br /> CHECK# PERMITAMOUNT SURCHARG AMOUNT FEE CODE RECEIPT# Je <br /> B <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) n 1 <br /> \ �{, <br /> -� DATA PROCESSING COPY <br /> 0 -13 . v <br />