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STATE OF CALIFORNIA-- WATER RESOURCES CONTROtrQVARD ": : .'"..\ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM V10 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .ow�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM <br /> El INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE IV <br /> 3 <br /> -4] 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORI�AC ON <br /> P /✓L/ <br /> ADDRESS NEAREST CROSS/�STREET ✓Sor loi PARTNERSHIP El STATE AGENCY <br /> / '3 Cosh S Ct k' ❑ ON 13LOCAL-AGENCY 13FEODNL AGENCY <br /> IldNIOIIAL ❑ COUNTY AGENCY <br /> CITY NAME STATE 21P CODE SITE PHONE M,WITH AREA CODE <br /> fC CA `I Sap <br /> TYPE OF BUSINESS'. ❑ 2 OIS OR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or - #of TANK'# <br /> F-] 1 GAS STATION �FARM ❑ 5 OTHER TRUST LANDS ❑ ll� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME /� CARE OF ADDRESS INFORMATION <br /> //7 <br /> 5 `siT <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPOiSATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> i/INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sort indicate El PARTNERSHIP ElSTATE-AGENCY <br /> PORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTYAGENCY <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. II. ❑ III. ❑ <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# IF of TANKS BI SITE <br /> Z/ 10 1 a <br /> CURRENT LOCA�7eNCY FACILITY 1 1L APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER La O)`PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED p q <br /> (' 3 a p)— YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> c� <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 ON <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />