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STATE OF CALIFORA WATER RESOURCES COAL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM110 7 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 'L <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE <br /> RMAN LY CC SED SITE t• <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ` <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> uzrzl 4 � <br /> ADDRESS ENEAREESTCHOSSSTREET ✓tloe to Mv2le 0 PARTNERSHIP 0 STATE AGENCY <br /> /75 ,.. 0 CORPORATION 0 UI AGENCY 0 EEDERALAGENCY <br /> ❑ INGIVIDUAI 0 COUNTY AGENCY <br /> CITY NAME ZIP CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 ISTRIBUIOR ❑ 4 PROCESSOR ✓BOA 11 INDIAN EPA ID 9 <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION <br /> LANDS or ❑ X of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS NAME(LAST f IRST) PHONL N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intllcale 0 PARTNERSHIP ❑ STATE AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODG <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INI'ORMATION <br /> MAILING or STREET ADDRESS ✓Box to and cate 0 PARTNERSHIP 0 STATEAGENCY <br /> I 0 CORPORA110N Cl LOCAL-AGENCY 0 FEDERALAGENCY <br /> CITY NAME <br /> ClINDIVIDUAL Cl COUNTY AGENCY <br /> STATE ZIP CODE PHONE A.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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION N AGENCY K FACILITY ID N #of TANKS at SITE <br /> 3I I lWFcTc_//T�_;-1 <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I <br /> I <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F7 ED <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEECODE YES ❑RECEIPTNO G ,Yry <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 /> s, A <br /> FORMA(3-2-88) J` <br /> �' DT. PROCESSING COPE <br />