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STATE OF CALIFORIP WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o Z <br /> to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `4i,ronw�r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'& <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) � <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION jhk <br /> lcr_"tw n,rjlPl� <br /> ADDRESS NEAREST CROSS STREET ✓Butoirdirai C PARTNERSHIP C STATEAGENCY <br /> C CORPORATION ❑ LOCAL AGENCY C FEDERAL AGENCY <br /> ❑ INDNIDWIL ❑ COUNN AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 'i 6 <br /> TYPE OF BUSINESS: ❑ ISMIBUTOR ❑4 PROCESSOR ✓BOX if INDIAN EPA ID # <br /> ❑ i GAS STATION 3 FARM ❑ 5 OTHER TRUSRESET LANDS VATION dr ❑ If of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NiIIj� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate C PARTNERSHIP C STATE AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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 C PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.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 Of AGENCY# FACILITY ID Is #o/TANKS at SITE <br /> [1 C1I I I 1111 7 m 6 � <br /> CURRENT LOCAL AGENCY FACILITY ID in APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTIIICT CODE BUSINESS PLAN FILED DATE F LEO <br /> 23, 2 2 YES NO 6' <br /> CMEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT In 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(3-2-88) <br /> DATA PROCESSING COPY <br />