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r <br /> STATE OF CALIFORN a <br /> WATER RESOURCES CONTR�OARD $ <br /> FORM 'A': 3 <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION J �0 <br /> _ ° <br /> C. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONly <br /> ONE ITEM 2INTERIM PERMIT o ❑ 7 F NTLY CLOSED SITE ti <br /> 4 AMENDED P.RMIT ❑ 6 TEMPORARY SITE CLOSURE •0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) WI,�, <br /> FAC ILI /SITE NAME CARE OF ADDRESS INFORMATION W <br /> ADDRE S W <br /> NEAREST CROSS STREET ✓Bcxki W 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 GGWORAT E] LOCA LO --AGENCY Cl FEGER4 AGENCY <br /> CITY NAME Tr/' 0 INDMDUAL 0 COUNTY AGENCY <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS:( ❑ 2 DISTRIBUTOR 4 PR ESSOfl ✓Box if INDIAN EPA ID p CA <br /> ❑ I GASSTATION ❑ 3 FARM OTHER RESERVATION or ❑ N of TANK'S TRUST LANDS AT THIS SITE Q <br /> EMERGENCY CONTACT RSO#(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORM A ION & ADDRESS - (MUST BE COMPLETED). <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Born tO ir,d'.te 0 PARTNERSHIP <br /> Cl Cl $TATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> CITY NAME 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE q,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADORE - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Box to inEicale 0 PARTNERSHIP <br /> ❑ CORPORATION CLOCAL-AGENCY 0 STATE-AGENCY <br /> CI Y NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1(BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR OTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ III ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDM N of TANKS at SITE <br /> CUR RE LOCAL AGENCY F ILI IDN "PROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> PERMIT NUMPR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT N DE CENSUS TRACT <br /> ##///�J SUPERV�R-DISTRICT CODE BUSINES1P SN❑FILED NO ❑ DAT FILED <br /> o� 3 1 V V (/ aE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <br /> 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 13-2-88J <br /> DATA PROCESSING COPY - <br />