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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM "f m <br /> = o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C1LIFp RN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 63 (Y) <br /> Cil <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 9asr S D/1 Ad ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME l 7 STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> IQ CA <br /> TYPE OF BUSINESS: ❑ 2 TRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'S <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CO4E DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CO(lz NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAM <br /> f° � 1 <br /> MAILING or STREET ADDRESS �, ✓ El Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> _ CARE OF ADDRESS INFORMATION <br /> NA <br /> �WeCrs .1 <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE E PHONE#,WITH AREA CODE <br /> CITY NAME ZIP COD <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 /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> [ER <br /> UNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> El�l T47= odor <br /> APPROVED BY NAME <br /> PHONE#WITH AREA CODE <br /> T LOCAL AGENCY FACILITY ID�/�� <br /> NUMBER L/ LL ('P/EJRMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE <br /> EEJFILED <br /> 23, 2 3 -2 YES ❑ NO ❑ 6 <br /> # PERMIT AMOUNT SURCHARGE AMOUNT <br /> 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 ONLY. L) <br /> FORMA(3-2-88) • -.__-/ <br /> • DATA P OCESSING COPY <br />