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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> tr'• �7 <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> -. . o <br /> SITE FACILITY/SITE, INFORMATION and/or PE APPLICATION ..,Ira <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE C QIOR�' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 LY CLOSED SITE <br /> ONE ITEM E]2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE v <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NA I CARE OF ADDRESS INFORMATION <br /> / <br /> ADDRESS j N NEAREST CROSSVftbk MgP(OTION O `l qp QOCALAWO ❑ FSEi��A�G Y <br /> �/ S ► maG 16 1 Cl INW16UAL ❑ COLtM AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITI A CODE <br /> CA —0>SE—o-7-7 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR V Box if INDIAN RESERVATION or 1:1EPA IDN If of TANK's <br /> AT THIS SITE Q2 <br /> 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE I 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE A 23 SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ IIT.❑ <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 /> 3 <br /> F°LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY M FACILITY ID N M of TANKS at SITE <br /> /16 1 V/ 13 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-018 TR1 T CODE BUSINESS PLAN FILED DATE FILED <br /> 03 <br /> Z O 3� YES NO ❑ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> 3F RM A(3-2-88) _- <br /> 1Q—�cj—�51 <br />