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STATE OF CALIFORNf WATER RESOURCES CONTRA OARD <br /> uT w <br /> FORM 'A': _ "tea z <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE ~ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ID E]4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/ TE/NAMyE CARE OF ADDRESS INFORMATION <br /> la 1 (. a 1, ( 1 U(-- <br /> ADDRESS NEAREST CROSS STREET ✓BWrimm ❑ PARIND IP ❑ STATEAGENIX <br /> 4 m, _ � ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> LJIJ V .L}' TROPORAL ❑ LOCAL AGENCY <br /> CITY NAM F-1F__] -/ STATE ZIP�QD5 SITE PHONE I.WITH AREA CODE <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR Box if INDIAN EPA ID If ((�_//,'�E q of TANK'a <br /> E:] 1 GAS STATION ❑ 3 FARM 'OTHER TRUSTVLANDS ATION Vr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,Ra. <br /> L PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LA$T,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toirrdmate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME �(� CARE OF ADDRESS INFORMATION <br /> 'ZIV"c <br /> MAILING or STREET ADDRESS I/Box toimlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# If of TANKS at SITE <br /> O <br /> CURRENT LOCAL AGENCY FACILITY ID Ir • 4APPROVED BY NAME PHONE X WITH AREA CODE <br /> S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> a <br /> CENSUS TRACTX SUPERVISOR-DISTRICT CODE BUSINESS P SY❑FILED ND ❑ DTE FILEDa �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 ONL <br /> FORMA(3-2-86) <br /> • DATA PROCESSING COPY 0 <br />