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- i <br /> STATE OF CALIFORNImr WATER RESOURCES CONTROYBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> O/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -� <br /> 10 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET �✓� 5Proedinte D PARTNERSHIP D FATEAGENLY 00 <br /> DYCDHPOMTIaN 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTv_AG€Na <br /> CITY NAME STATE ZIP CODETE PH NE N,WITH AREA CODE <br /> CA 952E y/S 8'23 2 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box tl INDIAN EPA ID a <br /> ❑ RESE <br /> 1 GAS STATION ❑ 3 FARM ❑I 'OTHER TRUSTVATION LANDS or ❑ N of TANK'N <br /> AT THIS SITE Q <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D S. NAME(LAST,FIRST) PHONE N WITH AREA CCDE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> /5 323-5225 Della-�ceco M• `//5�823-27 <br /> NIGHTS: NAME ILAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ZG_ <br /> MAILING or STREET ADDRESS ✓$gownto indicate D PARTNERSHIP D STATE-AGENCY <br /> WCORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> k9,qmDAf D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATEZIP'4 7,Pt NE ,WITH AREA CODE <br /> 1/✓ �A �f} 9 7 J Z <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be£to indicate D PARTNERSHIP D STATE-AGENCY <br /> CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> 1/ 2 D INDIVIDUAL D COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE 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: I. ❑ II. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N o1 TANKS at SITE <br /> / 13 (0 moo / <br /> CURRENT LOCAL AGEN Y FACILITY IDN VED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT IRATIO DATE <br /> LOCATION QODE CENSUS TRACT SUPERVISOR-DIST CT CODE BUSINESS PLAN FILED DATE FI 'O gyp' <br /> C0/ �c3 Ci31C1J YES E] NO El /� Y A O <br /> CNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />