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STATE OF CALIFORN4m' WATER RESOURCES CONTROL�mOARD <br /> FORM 'A': _ c <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ( NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM V2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFO MgTION <br /> Es 'Qy qTREET <br /> ADDRESS NEAREST CROSS ✓ minmrate ❑ PARTNERSHIPSTATE AGENCY <br /> 3 ' N COHPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> v1 INOIVDu 1 ❑ COUNTVAGENCYCITY NAME STATE SITE PHONE p,WITH AREA CODEOD <br /> 1 IJ CA <br /> TYPE OF SINESG ❑ 2 DISTRIBUTOR ❑a PROCESSOR ✓Box it INDIAN EPA ID a <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION or #of TANK'a <br /> ❑ ❑ TRUST LANDS ❑ AT THIS SITE <br /> [- J EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) P�HONE#WITH AREA CODE DAYS: NAME(LAST,FIRSTI PHONE a WITH AREA CODE <br /> V <br /> NIGHTS'. NAME If ST,FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MCI: OvqTgN5 <br /> MAILING or STREET ADDRESS ✓Odrtolodic.t. ElPARTNERSHIP 13STATE-AGENCY <br /> CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> L { ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> E — <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME E OF ADDRESS INFORMATION <br /> 1)S24 <br /> O' C <br /> MAILING or STREETADDRESS ✓ to indicate Ll PARTNERSHIP ❑ STATE-AGENCY <br /> ) CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> L, I ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ITV AME TATE ZIP CODE HONE WITH AREACODE <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. y 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APP VED BY NAM N PHONE#WITH AREA CODE <br /> a <br /> PERMIT NUMBER PERMIT APPRCO�VVA ATE PERMIT EXP ATIO DAT <br /> 6 U <br /> LOCATION CODE CENSUS TRACT# SUP RVIS -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHE # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ONLY.. <br /> F RM A(3-2-88) <br /> .\ DATA PROCESSING COPY 11�( <br />