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J• <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROBOARD <br /> .. <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE RNA' <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 /`NENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SV IV <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) -4 <br /> FACILITY/SIM CARE OF DDRESS INFORMATION w <br /> ADDRESS /IVE/SWCARO$65LEET By A ❑ PARTNERSHIP El STATE AGELY2 �. ' MRATON 11 LGLAGENLY 11 FEDERAL AGEC <br /> 1INDNIDAL <br /> ❑ COUNIY-AGENCY <br /> CITY NAME u STATE ZIP CODE �D ITE P NE N.WITH AREA CODE <br /> CA `�S"Z og ,Aa-? 3 <br /> TANKs <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 CES60R -/Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUSTYLANDS ATION of ❑ JQ ATITHIISSITE o0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(( T,FIRST) PHONE N WITH AREA CODE DAYS'. PHQJJE N WITH AREA CODE <br /> T <br /> NIGHTS: NAME( ST) PHONE WITH AREA CODE NIGHTS E(LAST,FIRST) PHO WITH AREA CODE <br /> S at & <br /> II. PROPERTY OWNER INFOR ATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF DRESS IN FORMATION <br /> f A <br /> MAILING or STREET ADDR SS / ✓Box to indicate PARTNERSHIP 1:1 STATE-AGENCY <br /> (,✓�t/. 1:1 11 <br /> LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> Le a ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMST ZIP CODE PHONE N,WITH AREA CODE <br /> Q 1 C� r2wo <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME .A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 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: I. Ff� it. ❑ 111.❑ <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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID IF IF of TANKS at SITE <br /> ® Q� 10 1 C) I / 3 = � 60 'p I ip <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> _ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHECK <br /> LN <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES Ej NO 0 2 <br /> 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 /> FORM A(3-2-88) go 0 <br /> DATA PROCESSING COPY ��j <br />