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STATE OF CALIFORA WATER RESOURCES CONTRIPBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : o <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 t+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE J N <br /> OD <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 4 <br /> FACILITY/ ITE I (L CARE OF AODRES�FORMATION <br /> I n I �- <br /> ADDRESS NEAREST CROSS STREET ✓Bw loilgirale CIPARTNERSHIP C STATE AGENCY <br /> 1 CO�EpB_ATIO0 ❑ LOCAL AGENCY ElFEDERAL AGENCY <br /> 1 <br /> OL.t 1 `B'IF,OMDUAL ❑ COUNTY AGENCY <br /> CITY NA STATE Z SITE PHONE#,WITH AREA CODE <br /> CA 13� 20 <br /> TYPE OF BUSINESS: <br /> ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box <br /> Bax It INDIAN EPA ID a <br /> I GASSTATION F—] 3 FARM OTHER RESERVATION or <br /> ❑ if of TANK's <br /> AT THIS SITE no <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAS ,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r'1 1 U.ea ('cEn n ( 2011U y6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERALAGENCYC INDIVIDUAL C COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP C STATEAGENCY❑ CORPORATION C LOCALAGENCYC FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE p,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 8 SIGNATURE) c DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCALAGENCYF FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> � ' 1ne5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACT# PSUPEASTRICTCODE BUSINESS PLAN FILED D T FILEDI'13 30p <br /> YES NO '�,CHECKM PEgM1TAMOUNT OUNT FEECODE 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 ONL . <br /> FORMA(3-2-88) <br /> • DATA PROCESSING COPY • <br />