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STATE OF CALIFORNI.0 WATER RESOURCESCONTRAOARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM " <br /> °m e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; roo <br /> Iff COMPLETE THIS FORM FOR EAC ACILITY/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 /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILI:ZE NAME CARE OF ADDRESS INFORMATION INN.) <br /> ADDRESS NEAREST CROSS STREET ✓ft 1.Mole ❑ PARTNERSHIP ❑ STATE AGENCY <br /> jnd E ��� ❑ G_ OHPOy61ION Cl LOCAL AGENCY ❑ FEDERAL AGENCY <br /> OVAL ❑ PAUNTYAGENCY <br /> CITY NAME STATE ZIPCODE SITE PHONE p,WITH AREA CODE <br /> L�scRto�1 CA s , <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # - <br /> ❑ I GASSTATION 3 FARM ❑ 5 OTHER RESERVATION o ❑ a of TANK's / <br /> I TRUST LANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA7) CARE OF ADDRESS INFORMATION <br /> MAILIN ;STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ �,BRPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY <br /> �N DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE—r ZIP ODE PHONE#,WITH AREA CODE <br /> nT <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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. VIll. ❑ <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 R AGENCY N FACILITY ID At It of TANKS at SITE <br /> [n = = 1 1 141a ,;)- 1 '4 <br /> CURRENT LOCAL AGENCY FACILITY M APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER V^ a^(, PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> E CEN TRAC�� SUPERVISSO-DISTRICT CODE BUSINESS PES N❑FILED ND ❑ DATE FILED <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At 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-SS) <br /> ifDATA PROCESSING COPY <br />