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.atop r+ <br /> STATE OF CALIFORNIP WATER RESOURCESCONTROIL9OARD <br /> SE'�`iU oe� j'yf <br /> uP: <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWPERMIT 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> LnuedaceStalbN <br /> ADDRESS NEAREST CROSS STREET ✓Rwbindrale 0 PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL <br /> ❑ INON1011 ❑ COUNTY-AGENCI <br /> CIN NAM STATE ZIP CODE SITE PHONE k,WITH AREA CODE N <br /> J,ijCA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR 7 4 PROCESSOR ✓BOX if INDIAN EPA 10 It <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYANDS ATION OI ❑ ATT IS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA C00E 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 ✓Box to indicate ❑ PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <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. ❑ if. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> o l O lo <br /> CURRENT LSO/CAL AGENCY FACILITY 10# APPR VED BY NAME PHONE a WITH AREA CODE <br /> V i� I <br /> PERMIT NUMBER PERMIT APPROVALD TE PERMIT EXPIRATION DATE <br /> / ) <br /> LOCATION CODE CENSUS TRACT SUPERlintost-nibI CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMITAMOUNT 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 ONLY. <br /> FORMA(3-2-88) <br /> A <br /> \�/ • DATA PROCESSING COPY <br />