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STATE OF LALIFORA WATER RESOURCES CONTRINOARD .`..... <br /> FORM `A': u__ f <br /> UNDERGROUND STORAGE TANK PROGRAM =" �e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•aea`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 1"'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O IV <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) OD <br /> I" <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> la n P M1 1 - ` �erT <br /> ADDRESS ^ NEAREST CROSS STREET ✓ @ ❑ PARTNERSHIP Cl STATEAGENCY <br /> ( f'. y..;., ,�. - i n ( RPOMTION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> C. 1 `v 1 ❑ INDNIOUAL Cl COUNTY AGENCY <br /> CITY NA#AE STATE P CODE SITE PHONE#,WITH A EA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID N <br /> RESERVATION or #of OTHTANK ss (� , <br /> ❑ 1 GASSTATION ❑ 3 FARM ER TRUST LANDS ❑ ATTHISSI <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 /> L-0ji r I ma Y <br /> NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST}----- PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> m � Le-R <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY����11//��---��//�� ,,••-'�� ❑ ORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> V� 0 �� A�..+� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP�ODE ��� PH ONE pO,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) /O1` 3 <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.,STREET ADDRESS ✓Bax W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <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)BOK 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® I Oo l 14b I I b I o 10 101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT' <br /> SUPERVISOR-D STRI CODE BUSINESS PLAN FILED O ED (X <br /> ZL_ YES ❑ NO ` I • �IU <br /> CHECK# 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) <br /> DATA PROCESSING COPY <br />