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STATE OF CALIFORN6r WATER RESOURCES CONTROrBOARD <br /> I F <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> C COMPLETE THIS FORM FOR EACH FACIL TY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT T CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> v <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS _ NEAREST CROSS STREETxale 0 PAATNEFlRIIP 0 STATEAGBICP <br /> U70N ElLOCAL AGENCY EIFMk AWO <br /> INDNIDIAI 0 CWNIY-AGENCY <br /> CITY NAME Y STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA S� S <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ d P R ✓Box if INDIAN EPA ID # <br /> If of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER 7gUSTV ANDS or ❑ ATT IS 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 /> w r>7Hn/ X35 6 CDE <br /> NIGHTS: NAME(LA ,FIflST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PRONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓-B6x to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> /J CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> /moi 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP C +E�- PHONE#,WITH AREA CODE <br /> 7�✓ X55 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: I. ❑ 11. 111. ❑ <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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID Is k of TANKS at SITE <br /> in / = bo 0 <br /> CURRENT LOCAL gGf NCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> 125- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT#_ SUPERVISOR-DISTRI T CODE BUSINESS PLAN FILED DATE FILE <br /> YES NO <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATON(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) S <br /> �!l DATA PROCESSING COPY � <br />