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STATE OF CALIFORNIA* WATER RESOURCES CONTROL BOARD <br /> W: •,A <br /> FORM 'A': : ., gym <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SjFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE �"`IFO"NSP F� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 TLY CLOSED SITE y <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE f • <br /> II' <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> ADDRESS J NEAREST CROSS STREET ✓Box toiidicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (/�f �G�/"" �/(O✓ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME + STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /� 'L^J a4 CA Jr <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK a <br /> RESERVATION or AT THIS SITE <br /> i <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#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> r <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME (d <br /> CARE OF ADDRESS INFORMATION <br /> • <br /> MAILING or STREET ADDRESS ✓B o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Ot 11 INDIVIDUAL ClCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> C� IA9- <br /> III. TANK OWNER INJORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> OvL G <br /> MAILING or STREET ADDRESS ` ✓ x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Gam^ t CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r4 f, ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> a Cd <br /> IV. LEGAL NOTIFIC TION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 1:1 II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO &ECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 1310G1010= <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> RIF 6 C' elo <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED ❑ DAT FILED �/� <br /> ] RYES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> ORM A(3-2-88) 0 <br /> .N�j <br /> DATA PROCESSING COPY <br />