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STATE OF CALIFORA WATER RESOURCES CONTR BOARD P <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Awo z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : I c <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGEOFINFORMATION ETrPERMANENTLY CLOS SITE F'+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,lc-w C--9_ J c�i� R _ G c mitis-c�` F <br /> ADDRESS NEAREST CROSS STREET ✓SOWxli¢te ❑ PAATNEAEHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOX AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUND-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA asp y <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION or ---'-- X of TANK's <br /> ❑ 1 GAS STATION ❑ 3FARM 2-5'&THER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> (�'1 <br /> NIGHTS'. NAME fLA$T,FIR ) PHONE#WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING orSTREET ADDRESS ✓Box to indicate IJ PARTNERSHIP ❑ STATE-AGENCY <br /> �� �L�1 El CORPORATION 11LOCAL-AGENCY EIFEDERAL-AGENCYa lJ y_T � L�}�(x Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 0 STA DECODE PHONE#,WITH AREA CODE <br /> V--(:n � q 1,4,-t() I A O 9 V, 53z <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCYCl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. FkKIII.❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# Al of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE X WITH AREA CODE <br /> S a-- ) <br /> PERMIT NUMBER PERMIT APPROVAL DATE - PERMIT EXPIRATION DATE <br /> LCHEC!Ki <br /> N CODE C <br /> ENSUS TRACT SUPERVISOI I��T CODE BUSINESS PLAN FILED ❑ DATE FILED <br /> YES NO <br /> 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 /> \YYT,T\`/I1I <br /> 1 FORM A(3-2-88) S <br /> � DATA PROCESSING COPY • <br />