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STATE OF CALIFORNIA'- WATER RESOURCES CONTROtMARD l <br /> 9a. h� <br /> ' auaaai � �i <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I p <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•aex`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1VCHANGE OF INFORMATION 7 PERM ENTLY CLOSED SITE I-Ax <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> m <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) I" <br /> co <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> k1kNic(4 <br /> ADDRESS l/� n ✓e. I NEAREST CROSS STREET viGue ❑ PApINEI5711P ❑ STATE"AGENCY <br /> -/ L _a� COR'OMTION ❑ LOGI"AGENCY ❑ FEDERk AGDO <br /> CITY NAME STATE ZIP CODFy. SITE PHONE N,WITH AREA CODE <br /> 16KAMP CA <br /> TYPE OF BUSINESS: ❑ DISTRtBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID It #of TANK'S <br /> ❑ ❑ TRUST LANDS VATION or ❑ <br /> t 00.5 STATION 3FARM 5OTHER 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 /> v/ <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 /> MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,^1 <br /> -33 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> A->–r ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE I ZIP/CCO�DE PHONE p.WI H AREA CODE <br /> –/f V <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �s7,xe a S <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. vII. ❑ Ill. ❑ <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 R FACILITY ID N R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACIE TY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION(CJg�DE CENSUS TRACT M SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> G? 1 2 3 Z '� YES NO � 6 <br /> CHECK# 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(3-2-88f <br /> DATA PROCESSING COPY <br /> L./ Now <br />