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i o - <br /> SEP`i�,�t:rMf <br /> STATE OF CALIFORNIP WATER RESOURCES CONTRO OARD A <br /> { <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT F-1 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO/S-E�D SITE N <br /> MARK ONLY ❑ V QO <br /> F_ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ED TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FSGLITY/SITE NAME I c CARE Ori ESS INFORMATION <br /> If-11 Q�YI e.C-I1"C C/LJ J�"LICA K l ll <br /> 4AD <br /> CROSS STREET ✓fba WiNicak ❑ PARINEASHIP ❑ STAiEAGENCY <br /> ADDRESS _ ❑ COAPOM"ON 0 LOCAL AGENCY ❑ FEDERAL AGENp��S O OY'L 0 iNDIviDUAL 0 COUNn ACENaCITY NA`MEE( ZIRGOD)=_ SIT ONE p.WITH AREA COLE <br /> TYPE of BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN - (`-]I�)PT U #of TANK's (—�1�� <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) LSI 2�_ <br /> K 11 O 7 <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNERINFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME 'nnAA 44 <br /> r 'v\ <br /> ✓Box to RATIIO Cl PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> El CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> ECAREDRESS INFORMATIONNAMEMAILING or STREET ADDRESS 11 o indicate 0 PARTNERSHIP ❑ STATESAGENCV <br /> PORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> DUAL 0 COUNTY-AGENCV <br /> ZIP CODE PHONE#.WITH AREA CODE <br /> CITY NAME <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. 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> EE= e = <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> KDLR G 1 o PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSPLANFILED NG ❑ DATE FILED <br /> a 300 L4i 5 <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY v <br />