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;TATE OF CALIFORNIA`` WATER RESOURCES CONTROCVbARD r:9 ' <br /> ORM 'A': UNDERGROUND STORAGE TANK PROGRAM .o <br /> `° - ro <br /> ITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION otal <br /> COMPLETE THIS FORM FOR EACH FA TY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEFIMAAUIjTjX.CLaUQ <br /> SITE <br /> ONE ITEM ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1(/o•c_ <br /> FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �'► <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Pfl y ixS A0 <br /> ADDRESS NEAREST CROSS STREET El CO iCN 11UCALAGM 13 �TDEML408I <br /> �.' . 9 �t e /,2/7 RJ ❑ IND"—... ❑ f-0IINfY-A6ENC/ <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> �Scu ( .✓ CA 9 53P2a <br /> TYPE OF BUSINESS: 2 DIS OR 4 PROCESSOR ✓BOX A INDIAN EPA ID # F of TANK'S <br /> ❑ ❑ RESERVATION LANDS <br /> EMERGENCY <br /> ❑ ATTHISSITE <br /> r71 GAS STATION FARM E]SOTMER <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 /> 7' Cj( u9tom- 54wy <br /> NIGHTS: NAME( T.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST FIRSTi 5�aL�Q PHONE N WITH AREA CODE <br /> 9a sn C 'b646— <br /> PROPERTY <br /> b64"PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> aju above _T , <br /> MAILING or STREET ADDRESS ✓So indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE$1,WITH AREA CODE <br /> I. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C5 If abut S . <br /> MAILING or STREET ADDRESS ✓Bo to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> ❑�B[1PRORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION# AGENCY# #of TANKS at SITE <br /> 3 � 141 -; 1010 <br /> b U i <br /> CURRE OCAL IDAPPROVED BY NAME PHONE N WITH AREA CODE <br /> 2_ <br /> PERMIT NUMBERERMIT APPROV PERMIT EXPIRATION DATE <br /> LOCATION CODE SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O/ YES NO <br /> 10 <br /> CHECK# lO SURCHARGE AMOUNT FEE CODE RECEIPT p 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 INFOFrMATION ONLY. <br /> FORM A(3-2-88) <br /> P �� ��q\ DATA PROCESSING COPY <br />