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A• <br /> STATE OF CALIFORNI9WATER RESOURCES CONTROL ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V j <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �0 o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE ED SITE I"a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 3 a) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 4=11 <br /> to <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓B bw ❑ PAMNER54W ❑ STATE#GEM,Y <br /> i/�P a ❑ . .T& ❑ LGCALAGDO ❑ FEDRk-AGENCY <br /> GIUL ❑ cauxn AGINCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S IVn CA S d 5­ 1 K&__ <br /> TYPE OF BUSINESS: ❑ 2 IBUTOR ❑ 4 PROCESSOR I ✓Box N INDIAN EPA ID N <br /> RESER❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ATION or ❑ u`l- 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 N WITH AREA CODE <br /> SIFj Z . <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 /> S/,¢ Z <br /> MAILING or STREET ADDRESS ✓Boxt tale Cl PARTNERSHIP IllSTATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> rDl NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME c CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ 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. II. ❑ 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 N AGENCY# FACILITY ID N N of TANKS at SITE <br /> U Io U / <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,P <br /> 9 3�3 3 YES ❑ NO 6/v_ <br /> CHECK N 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 ONLY. <br /> FORMA(32-813) <br /> DATA PROCESSING COPY �/ <br />