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-STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM a o <br /> _SITE FACILITY/SITE, INFORMATION and/or PER PPLICATION <br /> COMPLETE THIS FORM FOR EACH F TY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ffr5 CHANGE OF INFORMATION ❑ 7 PERMANENTV CLOSED SITE •+ <br /> ONE ITEM ❑ p INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ le C PARTMBBiIF C STALE-AGNM <br /> �c�- 11 WDMDu p 0 1 owm Accr 11EoEMI-acRx <br /> CITY NAME STATE ZIP CODE SITE PHONE a.WITH AREA CODE <br /> S o CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PRXESSOR ✓Box if INDIAN EPA ID a a of TANK's <br /> ❑ t GAS STATION ❑3 FARM ❑ 5 OTHER RESE <br /> TRUSTYLANDS nr ❑ I AT THIS SITE D <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(U+ST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> ,II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 1/130.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> VIII. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SaY <br /> MAILING Dr STREET ADDRESS ✓Box ID indicate 111 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 p,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. ❑ Ill. ❑ <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 a JURISDICTION a AGENCY N FACILITY 10 a a of TANKS at SITE <br /> 3 d W o <br /> RENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> 01— r <br /> PERMIT NUMBE V PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> � + LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CHECK* PERMIT AM UNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPT MU ❑ BY: <br /> yTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) �. <br /> DATA PROCESSING COPY <br />