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T\ <br /> STATE OF CALIFORNLXr WATER RESOURCES CONTROt'BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V Wit" <br /> SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION P z <br /> ,_i_ COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�none�" <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE G 0 N <br /> �J 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS—(MUST BE COMPLETED) I"& <br /> FACLITY/SITE NAME Wumiup ,1�.,g (n CARE OF ADDRESS INFORMATION 0 <br /> U1 <br /> ADDRESS NEAREST CROSS STREET ✓filo vAicale ❑ PARTNBRWP ❑ yTATE AGBLY <br /> !J13GOWMTON 0CN <br /> -33 LG -AGFNLY 11 FEGEML AGENCY <br /> 0 IIMIIWAL 0 COUNTY-AGENCY <br /> CITY NAME <br /> �r ,r STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> J CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR ✓Bol if INDIAN EPA ID# <br /> ❑ f GAS STATIONRESE[:]3 FARM ❑5 OTHER TRUST LANDS or El #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 10,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ❑ 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 N AGENCY# FACILITY ID# K of TANKS at SITE <br /> m = U <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> I-� .S <br /> PERMIT NUMBER PERNTAPPROVALOATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR•DISTRICT CODE BUSINESS PU1N FILED DATE FILED <br /> YES E <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 0 Y. <br /> FORM A(3-2-88) <br /> '�.. DATA PROCESSING COPY .,,. <br /> I <br />