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STATE OF CALIFORNIA) WATER RESOURCES CONTROL OARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> v COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT Rif CHANGE OF INFORMATION ❑ 7 PE TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / I <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Baf{i ntliMe ❑ P/ EINIIP ❑ STATE AGDO <br /> D WIPOPATAN ❑ LOCAL-AGDO ❑ FEDEMLAGENLY <br /> ❑ INDIADUN ❑ Cimm-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S c�K CA CF} 00 3- 5000 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID N -�,, e N of TANK'. <br /> F-1t GAS STATION F__] 3 FARM OTHER TRUSRESETVLANDS or ❑ �v`N, `''� 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 /> F`'R4 r& RT C 3- 00D <br /> NIGHTS: NAME( ST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Same �ao�i - 55'x' <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING or STREET ADDRESS ✓ ox m indicate CI PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 N AGENCY N FACILITY ID N N of TANKS at SITE <br /> DE = = loloI115_-TSN 1010O 171 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 11 L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK <br /> DE CENSUS TRACT N SUPERVISOR-DISTj1CODE BUSINESS PLAN FILED DATE FILED(y <br /> Q L . v aYES <br /> N O p� 6 <br /> PERMIT AMOUNT SURCHARGE AMOFEE CODE RECEIPT N 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 INFORMATION O� <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />