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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM 10 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cql FpR \P <br /> MARK ONLY F-] 1 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CTS <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate CORPORATION ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ E] LOCAL-AGENCY ❑ FEDERAL-GENCY <br /> El INDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAM STATE ZIP COD TE PHONE#,WITH AREA CODE <br /> cA 1'� o� -3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LATNDS ION or ❑ AT THIS SITE <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 /> or aoy 31� ir <br /> NIGHTS: NAME(LAST,FIRST)] PHON WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I11. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME �� / CARE OF ADDRESS INFORMATION <br /> CG,,IK <br /> ScL� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 /> . [ I j <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I 1 -7 �® <br /> CURRENT LOCA AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> V I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE . <br /> LOCATION CODE CENSUS TRACC SUPERVISOR-DISTRCODE BUSINESS PLAN FILED DATE FILED 1 <br /> I 1? O✓(► 3 t YES ❑ NO ❑ b <br /> CHEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: l <br /> r <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 /> FORMA(3-2-88) <br /> �� • DATA PROCESSING COPY • <br />