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STATE OF CALIFORNO WATER RESOURCES CONTRAOARD '"`'t`` <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , go <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) co <br /> co <br /> FACILITY/SITE NAME P� CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓RaxmiMicate O PARTNERSHP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> 7-r—ec. ❑ INDIVIDUAL ❑ COUNIY AGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> escc_l 01 CA 20/-'938'-,691 b <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID n If of TANK's <br /> ❑ 1 GAB STATION 3 FARM ❑ <br /> 5 OTHER TRUSTVATION LANDS o ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYSNAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to iodloate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. 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 Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. El <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 /> COUNTYIN JURISDICTION 4 AGENCY A FACILITY ID If R of TANKS at SITE <br /> ff;t <br /> FACILIT ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> SUS RACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE <br /> /FI EO <br /> 7 ^/"1JYES E] NO �MIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X 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) J <br /> DATA PROCESSING COPY <br />