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STATE OF CALIFORM9 WATER RESOURCES CONTRbeBOARD �` °� <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `°cnoc��P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S —4 <br /> W <br /> 1. FACILITY/SITE INFORMATION & ADDRESS -(MUST BE COMPLETED) I"+ <br /> IV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> +M -c\ 1_ <br /> ADDRESS', II II ,,C/yD� /"� ,,Q NEAREST CROSS STREET ✓g oNc,e ❑ PAUNERSIW ❑ STATEAGENCY <br /> "1 l(/W (—�C–CL/vl U Rte` Q 130010 LOCAL AGENCY ElFmEau-AODICY <br /> 1 13INGMWAL __-2-Wg�­AGENCT <br /> CIN NAME ��N^„ O STATE ZIP ggD_E SITE PHONE N.WITH AREA CODE <br /> 1 CA `tea `l o <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID x #al TANK'# V� <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUSRESETvLANDS or ❑ AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRS_ PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME t I CARE OF ADDRESS ORMPTION <br /> MAILING or STREET ADDRESS ✓Box to iFdI.at. ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION -❑ LOCAL AGENCY Cl FEDERALAGENCY <br /> ❑ INDIVIDUAL UNW-AGENCY <br /> CITY NAME , CSTATE� SDE o s 21P ODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tom,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.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. ❑ 1L ❑ <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 If AGENCY# FACILITY ID If #of TANKS at SITE <br /> ® = = 1010UI5olblol_ <br /> CURRENT LOCAL AGENCY FACILITY IDM OU S-T,.] APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION E CENSUS TRACT N SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE ILED <br /> 1J�OjJ`1f� `IT YES E) NO aUL <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> I FORM A(3-2-SR) h <br /> IVA,`x/ !'� DATA PROCESSING COPY Z� <br />