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STATE OF CALIFORNO WATER RESOURCES CONTABOARD SkPE o., -.�•� <br /> FORM `A': �. s <br /> UNDERGROUND STORAGE TANK PROGRAM W �+ '� Alt"" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r � ` �At <br /> � <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 10 <br /> =MARKONLY 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> Ej ❑ <br /> 2 INTERIM El <br /> 7 PEY CLOSED SITE h_L PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) v to <br /> FACILITY/SITE NAME <br /> �f CARE OF DD14ESS INFORMATION <br /> ADpRES I <br /> t`Q� ) / N R. TCR STREE ✓Aor10Ildiute ❑ PARTNERSHIP 0 ST TE-AGENCY <br /> [[ LJ <br /> A % l+Ji1 ❑ CGRPOPATIGN ❑ LOCAL AGENCY 'ERAL-A <br /> CITY NAME ❑ INDIVIDUAL Q COUNTY-AGENCY <br /> STATE ZIP C SITE PH NE#,WITH AREA CODE <br /> TYPE OF BUSINESS. CAi//�tJ <br /> DISTRIBl1TpR a�4=OTHERR <br /> =RESERVATION7or <br /> N II�� EPA ID r <br /> 0 1 GAS STATION iJ 3 FARM U LJ1 �of TANK'S <br /> AT THIS SI� <br /> EMERGENCY CONTACT PERSON(PRIMARY) L' EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY AME(LJST,FIRST) <br /> - PHONE#WITH AREA CODE D YS NAYF(LAST,FIRST) <br /> PHONE# ITH AREA CppE <br /> NIGHTS NAME LOST,FRS I) PHO #WITH AREA CODE NIGHTS AME(LAST,FIRST) <br /> PHON k WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> A CARE OF ADDRESS INFORMATION <br /> -SI <br /> Y <br /> MAILING or STREET ADDRESS -/BoxE103CORPORATION <br /> inGENCY <br /> dicate ❑ PARTNERSHIP <br /> Q LOCAL-AGENCY ❑ FEDER12 A AGENCY <br /> CITY NAME DUAL ❑ COUNTY-AGENCYZIP CODE PHONE#•WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ;//� <br /> ,// CAR=DRESS TION <br /> MAILING or STREET ADDRESS11 PARTNERSHIP <br /> ❑ CORPORATION ILl LOCAL-AGENCY ❑ FEDERSTATEAL-AGENCY <br /> ❑ INDIVIDUAL ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICK ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY pLT <br /> FACILITY 1D M <br /> #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 k APPROVED BY NAME <br /> I— PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATfON CODE CENSUS TRACT 8 SUPERV -DISTRICT CODE BUSINESS PLAN FILED <br /> DATE <br /> ` l YES NO r7 FILED_11 <br /> CHECK X PERWIIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS <br /> FORM A(3-2-88) THIS f5 A CHANGE OF SITE INFORMATION ONLY. <br /> DATA PROCESSING COPY <br />