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t <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL APdalti <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM Y _ "moo <br /> SITE O FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /7 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> t ^ F <br /> J fV <br /> ADDRESS _ NEAREST CROSS STREET �13 <br /> Sox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Co <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ` INDIVIDUAL ❑ CAUNTv.AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> ESC/ CA , <br /> TYPE OF BUSINESS; 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if IND AN EPA ID p <br /> RESERVATION or R of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM 5 OT TRUST LAND AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS.', NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ��1 (fZ — 7111 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: AME(LAST, IRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME {� Y/I CARE OF ADDRESS INFORMATION <br /> (f' ✓ 49 - <br /> MAILING or STREET ADDRESS ^ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ <br /> /7 CORPORATION 11LOCAL-AGENCYFEDERAL-AGENCY <br /> VV ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PH NE#.WITH AREA CODE <br /> —2 <br /> III. TANK OWNER INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ DER ,AIGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> /'I IV. LEGAL NOTIFICATION AND BILLING ADDRESS �f CA <br /> S' <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# AGENCY# FACILITY ID# #of TANKS et SITE <br /> El Er I I L01�21 / 19 YE If-910 jc)�31 <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 /> �� YES NO _711�I <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�INLY. <br /> FORMA{3-2-88} � � III <br /> DATA PROCESSING COPY <br />