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OF- <br /> STATE OF CALIFORNIA WATER RESOURCES CAROL BOARD <br /> v: <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO ° o <br /> C <br /> COMPLETE THIS FORM FOR EAC H F ILITY/SITE 'IFa^"r" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED SITE Ij <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE o/ <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> fV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> un <br /> ADDRESS NEAREST CROSS STREET ✓3.'ro ML, 0 PARTNERSHIP 0 STATE AGENCY <br /> /� ❑ CORMHATIDN D L=LAGDICY 0 FEDERAL MENEY <br /> /p / ` ❑ NDNIDUAL ❑ WUNTYAGB+GY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WIT EA E 3 <br /> ryj ire 1-e S3 3 (o CA gS33 a Z <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID # <br /> IRESEf TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTYLANDS ATION or It /✓OiL/,E ATTHISSITE <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#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> !'!7 / !iC$f'r�T H T A <br /> MAILING�or STREET ADDRfi62S ✓ x to indicate D PARTNERSHIP Cl STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 7 U! ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> vale 5 fa CA 1 9'S3ii roll <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSx,.,ndicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> D <br /> CORPORATION 0 LOCAL-AGENCY FEDERAL-AGENCY <br /> 69'B' D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NX ' STATEZIP CODE PHONE#,WITH AREA CODE <br /> n /e e� 5334v <br /> W. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ 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# AGENCY# FACILITY IDR #of TANKS N SITE <br /> 3 o a I o I o <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> v u 15,- <br /> PERMIT <br /> sPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE 0EN8USTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED pQ <br /> ® a 3 r YES NO �O / <br /> CHIPERMIT AMOUNT SURCH GE BUNT 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. <br /> FORM A(3-2-BB) <br /> DATA PROCESSING COPY \ <br />