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LIFOR& WATER RESOURCES CONY UL BOARD <br /> STATE OF CA <br /> FORM `A': W <br /> UNDERGROUND STORAGE TANK PROGRAM z <br /> r ���. �" �o 10 <br /> SITE ACIIlITYISITE, INFORMATION and/or PERMIT APPLICATION ,/ <br /> Cq.�IFO NN�� <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY � 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OP INFORMATION ❑ 7 PERM,r� OSED SITE <br /> ONE ITEM � 2 INTERIM PERMIT '� 4 AMENDED PERMIT <br /> El 6 TEMPORARY SITE CLOSURE D N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> Q <br /> CARE OF ADDRESS INFORMATION <br /> FAGIUTY/SITE NAME <br /> r0� NEAR T CROSS STREET ✓&X to i RA71e ARTINELOCAL- SHiFAGENCY <br /> ❑ $TATE-AGENCY <br /> ADDRESS � ❑ G{7APORATION Cl LGCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r� 011. ❑ INDIVIDUAL ❑ COJNTY-AGENCY <br /> fL.� STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CITY NAME / J CA <br /> EPA ID n p 61 TANK'S <br /> TYPE of BUSINESS. p DISTRIBUTOR 4 PROCESSOR V Box It INDIANRESERVATION or AT THIS SITE <br /> I GAS STATION E] 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> PHONE#t WITH AREA CODE <br /> DAYS, NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> 0 I/111, PHONE#WITH AREA CODE <br /> NIGHTS: NAME FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST.FVRST) <br /> 6 C,IK PVU)-Vl - <br /> X373 r - 1 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> WNAME ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D 5 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ COUNTY-AGESTATEZIP CODE PHONE H.WITH AREA CODE <br /> o�L <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPCARE OF LETED)SS <br /> NAME ^ L <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY C� FEDERAL-AGENCY <br /> + ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> ` STATE ZIP COD PHONE#.WITH AREA CODE <br /> CITY NAME <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. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLlOANT'S NAME(PRINTED 8 SIGNATURE} <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> l � QL <br /> NE#WITH AREA CODE <br /> APPROVED BY NAME PHO <br /> FCURRErOCAL AGENCY FACIS IT�# <br /> ©G 1�Y1'1 [ff, <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT COD€ BUSINESSY S FILED NO 41 0 , <br /> © 1 � RECEIPT# B <br /> CHECK# <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE COPE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111)OR MORE TANK PERMIT FORM 'B' APPLICATION{S},UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-BB) <br /> G' � DATA PROCESSING COPY <br />