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STATE OF CALIFORNHA' WATER RESOURCES CONTROOO�OARD <br /> (% Z <br /> FORM `A':SITE UNDERGROUND STORAGE TANK PROGRAMFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C_ COMPLETE THIS FORM FOR EAC FACILITY/SITE tG <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ RRENEWALPERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-L <br /> ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME Q <br /> CARE OF ADDRESS INFORMATION It <br /> f/ X71Q d D/J <br /> ADDRESS <br /> S� NEAREST CROSS STREET ✓Bo p dmk 1-1PAATNER7HIP 0 FATE.AGDO <br /> ❑ CAHPoRATION 0 LOCALAG9,0 0 FEDEMLAGENGY <br /> CITY NAME 0 INUMOIIAL D COIINWAGENO <br /> SSTATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑q PROCESSOR <br /> '/Box if INDIAN EPA ID ID p <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ESEVATION or El AT <br /> of TANK# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lointlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY D FEDERALAGENCY❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lo,rd,cale D PARTNERSHIP DSTATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 'CHECK (1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY N FACILITY ID N N of TANKS at SITE <br /> m = 15- 11-1 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED SY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23.6a 2� res No / 2 3 D <br /> CME N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: - I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPUrATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OHM A(3-2-SS) <br /> �� DATA PROCESSING COPY „� <br />