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STATE OF CALIFORNIA- WATER RESOURCES CONTROL'7116ARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; to <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Er5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C" <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CN <br /> A <br /> FACIA /SITE NAME C CARE OF ADDRESS INFORMATION <br /> b/j5_TpLji <br /> ADDRESSNEAREST CROSS STREET ✓Boa to ifdeft 13PANTNEBSHIP 11 STATE AGEIV <br /> /`�', ❑ CONPOMIIQY 13LOCAL AGENCY 0 RDEPAL-Ai <br /> CITY NAME STATEZIP CODE SITE PHONE a,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a <br /> RESERVATION or At of TANK'# <br /> E] 1 GASSIATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY i <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> I <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 1 <br /> CITY NAME STATE ZIP CODE PHONE a.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. ❑ III. ❑ <br /> ' I <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 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS at SITE <br /> m = = I I I / 9 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �lo/u� 93 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> CENSUS TRA # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED <br /> �J YES ❑ NO ❑ <br /> PERMIT 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />