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. <br /> Y,rod' <br /> STATE OF CALIFORNIT WATER RESOURCES CONTROL <br /> r <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br />1 " ' SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c'�',cn"- <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> ADDRESS NEAREST CROSS STREET ✓Bar WNdu 0 PARrNMIP 0 STATE-MOD <br /> ❑ MWOUTION 0 LOCAL-AGEIN.Y 11PEDERAL-AGERY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE P ONE N,WITH AREA CODE <br /> CA <br /> TYPEOFBUSNESS: ❑2 DISTRIBUTOR ❑ 4 PROCLS30fl ✓Bond INDIAN EPA ID N <br /> RESERVATION❑ ❑ ❑ TRUST LAND$Or ❑ #of HIS SITE 7 GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> sppmg <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ it. ❑ 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# F IDN - N of TANKS at SITE <br /> 13 L I <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED B — PHONE#WITH AREA CODE <br /> 1,F_JF_ <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION fOOE CENSUSTRACT# SUPERVISOR DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 <br /> 3 YES ❑ NO I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 /> I� FORMA(3-2-88) J <br /> 0 DATA PROCESSING COPY <br />