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STATE OF CALIFORNIA WATER RESOURCES CONTROLBOARD <br /> „ <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM ) <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE `����oar•�-" dL.. <br /> F0ARK,ONLY F—] I NEW PERMIT ❑ 3 RENEWAL PERMIT PK 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTEM ❑ P INTERIM PERMIT ❑ d AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 53 Q) <br /> r <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> EDenfLc, lwo--:4cxLc N <br /> ADDRESS NEAREST CROSS STREET ✓Bax lwdlute ❑ PARTNERSHIP 0 STATE AGENCY <br /> 3 �c70 c ❑ coRvoeanoN ❑ LOCAL AGENCY ❑ renEAaL.AGENcv <br /> ❑ INONIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> c7( JJ CA 9520` .`l�^ — --00/S—' <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR ❑ d PROCESSOR ✓Box iI INDIAN EPA ID If <br /> F-1I GASSTATION ❑3 FARM 5 OTHER TRUSR LANDS D ❑ 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 /> NIGHTS: NAME(LAST,FIRST) PHONE It 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 /> MAILING or STREET ADDRESS I/Go.to intlicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/80.to intlicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 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. IL ❑ 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 /> � mCOU�Y# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Lf ;e� I / 5 <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# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> \� <br /> HED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES E] NO <br /> ❑ BY; 0< <br /> THIS FORM MUS E ACCOMPANIE AT L�(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) . \ <br /> DATA PROCESSING COPY <br /> V` <br />