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STATE OF CALIFORNI* WATER RESOURCES CONTRdrfiOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m ; 10 <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE �""OP"�" <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE h.& <br /> ONE ITEM 02 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> � I <br /> FACIUTYB E NAME W CARE OF ADDRESS INFORMATION <br /> of Od <br /> ADDRESS NEAREST CROSS STREET ✓Sw b Mime ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 14� led ❑ MC <br /> nox FI ❑ FEUER4L AGENCY <br /> O 1/Ln, INOMOUAL ❑ AGENCY <br /> CITY NAME STATE ZI ODE SITE PHONE N,WITH AREA CODE <br /> j�yL CA S <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N _ M of TANKY <br /> RESERVATION or � AT THIS SITE <br /> 1 GASSTATION FARM 5 OTHER TRUST LANDS <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 /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIL Gar STRE ADDRESS ✓Box 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 /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ 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: L El it. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY M FACILITY ID• N of TANKS at SITE <br /> m 1 1 14 0 1 �av <br /> CURRENT LOCAL AGENC3'FSCILITY 100`/ APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBERJ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA99NCODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS <br /> I.P SN FILED NO <br /> O DATE/ D x� ^ <br /> �3,a3 <br /> Cmck N PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY. <br /> FORM A(3-2-813) <br /> ilr/ DATA PROCESSING COPY INA/ <br />