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• p•�--OIC j_., <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': V ^ <br /> UNDERGROUND STORAGE TANK PROGRAM = <br /> SITE D FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREQ y' a) <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) a) <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CRO SSTREET ✓Box toiMirate D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL ❑ COUNTYAGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE� <br /> �scwlo„ CA �53l- <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID a q�� lvOG U 7 J 7 If of TANK's <br /> RESE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUSTVLANDS or ❑ fes/ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) „ PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> TS'. NAME(U <br /> NIGH .FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or ST ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL D 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. ❑ it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION F AGENCYIV FACILITY ID 1f M of TANKS at SITE - <br /> 3 <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE <br /> D G nJ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ODE CENSUS TRACvT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> .23 . DU YES ❑ NO � V :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(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />