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STATE OF CALIFORN6c WATER RESOURCESCONTROL130ARD ^' <br /> F RM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITEn FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> l� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �;;-ICHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"A' <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> fV <br /> F ILITY/SITE NAME CARE OF/ARESS INFORMATION <br /> FAC <br /> dui i�,� r // <br /> ADDRE%..),.. NE REST CRO STREET ✓Intik m C PAATNBSIIP C STATE'AGENC/ <br /> C COAPGRAnON ❑ LOGL-AGDOFEGBUL <br /> ❑ INDMDIX C WUNTY-AGRICY <br /> CITY NA -"{^'"� STATCA ZIP CODE O SITE PHON p,WI H AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID It ] C7/V Mol TANK6'N <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS VATIONor ❑ AT THIS SITF0d__ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERIdENCY CONTACT PERSON(SECONDARY) <br /> DA N ME(LAST,FIRST) HONEN WITH AREA CODE DAYS'. yJ ME(LAST,FIRST) PHON I WITH AREA CODE <br /> NIGHTS NAME(IA ,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PH N N WITH AREA CODE <br /> S A S A t fa s A� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME S A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS F�WoI/ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C 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. Rj� 11. ❑ 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY N FACILITY ID If B of TANKS at SITE <br /> r G o0vz <br /> CURRENT LOCAL AGENCY FACIIJTY IDN APPROVED <br /> N PHONE N WITH AREA CODE <br /> SCS e / / <br /> PERMIT NUMBER PERMIT APPROVAL DATE P BABY EXPIRATION DATE <br /> LOCATION CODE CENSUS—5N'�� SUPERVISOR-DISTRICT CODE BUSINESS ESN❑ED NOa�r/ lDAM FILED <br /> .l[// <br /> CHECK N PERMIT AMOUNT SURCHARG O NT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST 6E ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ```jFO'M A(3-2-B8) <br /> 1�� DATA PROCESSING COPY `r <br />