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STATE OF CALIFORNIP WATER RESOURCESCONTROROARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM � o <br /> SITE --c FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° to <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 N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C 1 N <br /> QO <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) —4 <br /> 11 <br /> FACILITY_ SITE NAME CARE OF ADDRESS INFORMATION <br /> Scj-)n l Ld-4- -:1-5— <br /> ADDRESS NEAREST CROSS FEET ✓ft to Meme L] PMTNEFSHF 11STATEAGENCY <br /> C� S ` �(K 1` ❑ CDRPORAIIDN 0 LDGALAGENCY ❑ FEDEMLAGENCY <br /> ^� ❑ INDIVIDUAL Cl COIIN AGENCY <br /> CITY NAME STATE ZIPCODESITE PHONE#,WITH AREA CODE <br /> 20 15-1 OLP' <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i(INDIAN EPA ID p <br /> F-1I GAS STATION ❑3 FARM �OTHEfl TRUSTYLANDS or ❑ �— ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST,FIRST) II PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A.AYQ i <br /> NIGHTS. NAME(IAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME_ f �- CARE OF ADDRESS INFORMATION <br /> LAD <br /> C� <br /> MAILI;G STREETADDRE55 �y� ✓Box toinoicate 1-1PARTNERSHIP 1:1 STATE AGENCY <br /> Or 1-F Ra 13 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> M <br /> 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> S cJcEzo-Y-\, c - <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME '` ^ CARE OF ADDRESS INFORMATION <br /> N Y-b <br /> MAILING or STREET ADDRESS ✓Bax Io iftcate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION It AGENCY k FACILITY ID N If of TANKS at SITE <br /> d oi � a o <br /> CURRENT LOC4L AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> CN� � CC� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCODE CENSTRACT N SUPERVISOR-DISTYLCT CODE BUSINES;P N FILED D E FI Dl <br /> l 10 0BO-) Iv7 S NO . <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> DATA PROCESSING COPY 0 <br />