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STATE OF CALIFORNIlC WATER RESOURCESCONTRO IBOARD " <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; to <br /> 21 COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME `'/ CARE OF ADDRESS INFORMATION <br /> �Y b) <br /> ADDRESS //�]��' NEAREST CROSS STREET ✓ b xaie 0 PARTNERSHIP 0 STATE AGENCY <br /> `✓ / 'oV�/) �. ❑ IWRgPA�TON ❑ WGUNTY AGENCY AGENCY ❑ FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE S.WITH AREA CODE <br /> CA S3� <br /> TYPE OF BUSINE ❑ 2 DI UIOR ❑ d PROCESSOR -/Box if INDIAN EPA ID p <br /> ❑ 1 GAS STATION FARM ❑ 5OTHER TRUSTVLANDS ATION or ❑ If of TANK'S <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ 111.❑ <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 N JURISDICTION R AGENCY N FACILITY ID N N o1 TANKS at SITE <br /> m = = I I 14 10 <br /> CURRENT RL AGENCY FACILITY IDM APPROVED BY NAME PHONE It WITH AREA CODE <br /> PERMIT NUMB/EER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA N ODE CENSUSTRACTR SUPERVISOR-DISTRICT CODE BUSINES,PL PLAIN NO ❑ DATE 1/2 <br /> ES <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) - <br /> -*4w DATA PROCESSING COPY 100 <br />