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A SEP Iu o++'lMl' <br /> STATE OF CALIFORNO WATER RESOURCES CONTR BOARD <br /> -,- . T: <br /> FORM A: y <br /> a � UNDERGROUND STORAGE TANK PROGRAM =`�"�' Arom <br /> SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 9L, opvlP <br /> iCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PER ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ !1 <br /> ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE lJ00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) fV <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME � : <br /> l.( V� <br /> ADDRESS NEAREST CROSS STREET ✓�kicat, ❑ PARTNERSHIP ❑ STATE AGENCY <br /> J�cc oo I—� �$CORPORATION D LOCAL AGENCY D FEDERAL AGENCY <br /> V j,Q M I b— D INDIVIDUAL D COUNTY AGENCY <br /> CITY NAME STA E ZIP DE SITE PHONE#,WITH AREA CODE <br /> �(& , CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz P INDIAN EPA IN # #of TANK'# <br /> II��II `���..�,� RESERVATION or ❑ �— AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM Q,,^"R TRUST LANDS <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(IAST,FIRST) 9 PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME,.j J..'- n ` � J, �� <br /> CARE OF ADDRESS INFORMATION <br /> Box to Indicate D PARTNERSHIP El STATE AGENCY D <br /> MAILING or STREET ADDRESS /U�i�( � / `( ('y/'—� ✓ <br /> 3 n 1 ' 1 ✓� I D CORPORATION D LOCAL-AGENCY FEDERAL AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME / SlEr ZIP CODE PHONE# WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS K/J ✓Box to Indicate ❑ PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D 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 IF AGENCY# FACILITY ID# #of TANKS at SITE <br /> o = � <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> n i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA CENSILISTRACTJL_ SUPERVISOR- IS CT CODE BUSINESSSk <br /> !SN FILED NO D F E <br /> CHECK# PERMIT AMOOUNN_\fTSURCHARGE AMOUNT FEE CODE ❑RECEIPT# ❑ BY: <br /> qqq\\\\\\ 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 /> \, \ FORM A(3-2-881 <br /> 19 DATA PROCESSING COPY <br />