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STATE OF CALIFORNIA WATER RESOURCES CONTROROARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC AGILITY/SITE <br /> FMARKONLY F-1I NEW PERMIT [:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE g--I <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) VV <br /> FACILITY/SITE NAME CARE OF ADD ESS INFORMATION <br /> rs 6-re. e o P w P/S� NCE_ <br /> ADDRESS NEAREST CROSS STREET ✓Ba bidcek ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENGY <br /> ^� ❑ woNIDUAL ❑ COUNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> cam CA �O5— 2c�- _ /Zd <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESEATION <br /> ❑ I GASSIATION [:] 3 FARM ❑ S OTHER TRUSTLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> d $PAY a <br /> MAILING or STREET ADDRESS �` y ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �/12S L L�I�T/ % ❑ INDIVIDUAL <br /> 0 LOCAL-AGENCY❑ COUNTY AGENCY ❑ FEDERALAGENCY <br /> CITU NAME__ STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 1/80.toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION Al AGENCY k FACI If of TANKS SI SITE <br /> 2 G <br /> CU ENT LOCAL AGENCY FACILITY ID N APPROV PHONE N WITH AREA CODE <br /> Y <br /> PERMIT NU OVAL DATE PERMIT E%PIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �-Q 3'ZS YES NO 5 t/ <br /> CHEC M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY;_LZ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS ISA CHANGE OF SITE INFF—ORMATION ONLY:- <br /> FORM A(3-2-88) • • ` <br />