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M1 y�O k, SNf \ <br /> STATE OF CALIFORNI10 WATER RESOURCES CONTRABOARD W. <br /> FORM A': UNDERGROUND STORAGE TANK PROGRAM " " m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Y'1 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT DX, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 9 Z <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S fo c,K f r U ry <br /> ADDRESS , NEAREST CROSS STREET ✓Sa ioiMeate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION ❑ LOCA AGENCY 0 FEDEML-AGENCY <br /> go $ 1)), G[n r 0 N F O a, 0 iNOWDUAL ❑ ar NLaAGBNCY 1,0i41 <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE W <br /> S% fel C CA ao (d69) -'16,4i`-Y333 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIB TOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #/I #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS or ❑ J✓ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) p_,, PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHT NAME(!FIRST) e ` otiers ov PH NE ft WITH AREA CODE NIG O2 M�L�T,FIRST333 PHONE#WITH AREA CODE <br /> MorK N ow (,ao -kin <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PgINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COOUI JURISDICTION# AGENCY# FACILITY ID# .�// #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY <br /> = APPROVED BYONAME/ � / / POE#WITH AREA COD <br /> S oC FQ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> E CE S TRACT M SUPERVISOR•DISTRICT CODE BUSINESS P S N FILED NO ❑ DATE/LED <br /> tf <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 7 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 /> FORM A(3-2-88) 40 41 <br /> DATA PROCESSING COPY <br />