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STATE OF CALIFORNIX WATER RESOURCES CONTROYBOARD ^, <br /> A I <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® <br /> T_ l COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION Ee<PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY S1TE CLOSURE Fj <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEARF$ CROSS STREET ✓BwbMiule 13 PARTWISO 0 STATEAGEIK <br /> (./ ❑ COIPOIIA N ❑ LOCALAGENCY ❑ FEDEPAL-AGENl,1' <br /> ❑ INDMOINL ❑ COIKYAGENCI <br /> CITY NAME STATE ZIP CODE SITE PHO) II,WITH AREA CODE <br /> cA 5a o ao 3�0 — 7,P'/ <br /> TYPE OF BUSDJESS. [—] 2 DI auIf OR ❑4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> ❑ If of TANK's <br /> 1 GAS STATION FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE A'WITH AREA CODE <br /> ao 4 3& <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> te. • _� <br /> S ' _ — <br /> II. PROPERTY OWNER INFORMATION 8 ADDRESS — (MUST BE COMPLETED) <br /> NAME SI/4 , ^ CARE OF ADDRESS INFORMATION <br /> MAILING or REET ADDRESS -/�U, ✓Box to iMicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o STRE ADDRESS I/Box to,ftoale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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. ❑ II. ❑ If ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY B FACILI N of TANKS BI SITE <br /> 0� 0aa0 <br /> CURREN CAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LL <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS P NO NG ❑ DATE FILED <br /> YES <br /> IT AMOUNN(T SURCHARGE AMOUNT FEE FEE 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 <br /> FORMA(3-2-88) J' <br />