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STATE OF CALIFORNIP WATER RESOURCES CONTRO•OARD r+: <br /> FORM `A': e AT <br /> UNDERGROUND STORAGE TANK PROGRAM ' �� "gym <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °4r,.oaN�P n <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL F�ERMITE 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY <br /> ONE ITEM I E PV <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME N <br /> CARE OF ADDRESS INFORMATION <br /> e <br /> ADDRESS_ NEAR CPO SSTREET ✓SoxlmMiI El PARTNERSHIP 11 STATE-AGENCY <br /> 13p^^ CORPORATION 11LOCAL AGENCY 11 FEDERAL AGENCY <br /> CITY AME ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> L-10STATE ZIP CODE SITE PHONE k,WITH AREA COD <br /> L/�`lV/1• CA O ao 9 -��.S <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ q PROCESSOR ✓Box if INDIAN EPA ID q <br /> ❑ I GAS STATION 3 FARM ❑ 5OTHEA TRUSTVATION LANDSN ❑ #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(IAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> a a- <br /> NIGHTS: NAME(LAST,TT J: S PHO #WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> r CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS EEI <br /> Sox to Intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CI NAMEINDIVIDUAL ❑ COUNTY-AGENCY <br /> ZIP CODE PHONE p,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. ❑ II. ❑ 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 <br /> AGENCY� � USE ONLY <br /> ��--J JURISDICTION� AGENCY# � D f TANKSatS ITE <br /> 3 <br /> CURRENT CY FACILITY ID X �- APPROVED BY NAME PHONE M WITH AREA CODE <br /> F )S <br /> PERMIT NUMBER ROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# (J <br /> 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 S-2-13S) <br /> DATA PROCESSING COPY <br />