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or .. <br /> STATE OF CALIFORNIA,- WATER RESOURCES CONTROL..OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ." <br /> o <br /> SITE / FACILITY/SITE, INFORMATION and/or PE MIT APPLICATION <br /> C� COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P RMA SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SpZ <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS Q �/fT NEAREST CROSS STREET ❑✓�CO�OMTNIII O lOfAIAT QIP s Ar>ErvcY <br /> 5/S� G+�. 6G7S�hesS ❑ INl�MM ❑ CWMAGENCY <br /> CITY NAME STATE ZIP CODE ' SITE PHONE p,WITH AREA CODE <br /> CA 13-3-7,41 <br /> 3 3 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESWR ✓ ox if INDIAN EPA ID p A of TANK'S <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST YLor ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box to Indicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box to Indica(. 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ I. ❑ 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 R JURISDICTION B AGENCY N FACILITY IDR R of TANKS Al SITE <br /> p <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE p WITH AREA CODE <br /> PERMIT NUMBER n`fw) PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> JOZRMA(3-2-88) <br /> OCATION CODE CENSUS TRACT a SUPERVISOM.QISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �7 2 7 s(d 77 YES NO <br /> HECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: <br /> IS 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 />