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STATE OF CALIFORNIA9 WATER RESOURCES CONTROL OARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE T FACILITY/SITE, INFORMATION and/or PERMIT F APPLICATION o <br /> Y COMPLETE THIS FORM FOR EACH CILITY/SITE `"�•�^%`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 5 w <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A <br /> IV <br /> FACILITY/SITE MEc. �C {� aA� CARE OF ADDRESS INFORMATION( * �� <br /> ADDRESS ((11 NEAREST CROSS STREET ✓ISNUINicale ❑ PARTNERSHIP Cl STATE AGENCY <br /> 11 d L 11 CORPORATION ❑ LOCAL-AGBICY ❑ EIE,ALA li <br /> L6l.1/ r L VQ Qom^' 11INOMOOAI 11 COUNTY AGENCY r <br /> CITY NAME Ili_p O C i STATE 21P CODE SITE PHONE p,WITH AREA CODE <br /> CA P s zii-I v p 3bq <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ,F❑y4 PROCESSOR ✓BOx if INDIAN EPA ID # <br /> ❑ ❑ Cf � TRUSTVLANOS Or ❑ ATTHIS SIT <br /> 1 GAS STATION 3 FARM OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 /> S CL I <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME G CARE OF ADDRESS INFORMATION <br /> JCC PLLA <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P 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. it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY B FACILITY ID If #of TANKS at SITE <br /> N41 C) I U I I q I it I --1 I 1 U 1 U 1 O U <br /> CURRENT LOCAL AGENCY FACILITY ID N 1✓Ln APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS TRACT# SUPERVIS( II-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (('�q CLIA)�q a L V I YES [:3 NO t-(p -b I CcIA.) <br /> CHECK It PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> y"M A(3-2-88) 9 <br /> V�V/ DATA PROCESSING COPY <br />