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STATE OF CALIFORNIA' WATER RESOURCES CONTROLI(OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM _ m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' ; <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q <br /> IO <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /1/ N <br /> ADDRESS NEAREST CROSS STREET ❑ PARTNERSHIP ❑ i <br /> BIDLON ❑ L"LAGE [I FFDRAGEN <br /> CY <br /> 11 INDIVIDUAL ❑ COUNTYAGENCY <br /> w <br /> V� <br /> CITY NAME / STATE ZIP CODE SITE PHON ,WITH AREA CODE 00 <br /> CA G <br /> TYPE OF SINESS. ❑ 2 DISTRIB TOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID p If of TANK's <br /> ESE <br /> El3FARM 5 OTHER TRUSTYATION LANDS or ❑ AT THIB SITE <br /> 1 GAS STATION ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NAMNIGH NAME(LAST, ST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L{�hXvn T <br /> MAILING or STREET ADDRESS ✓ m intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE �r� PHONE p.WITH AREA CODE <br /> �.00 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> /Vr/✓ 19[ � I � <br /> L <br /> MAILI or STREET^^"""" ✓ io intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C��pp /J _ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> lotyl �_ o 6.1'r ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYNA STATE ZIP CODE ONE a 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: 1. if. ❑ 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# FACILITY ID If #of TANKS of SITE <br /> 1010 / Fo <br /> CURRENT LOCAL(,G�CIL TY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER/ S PERMITAPPROV� � /� PEE'RRrT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR- STRICT CODE BUSINESS PLAN FILED DATE FI / <br /> 7 YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <br /> 1 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(3-2-88) <br /> DATA PROCESSING COPY '� <br />