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STATE OF CALIFORNIAWATER RESOURCES CONTROSIOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ITT <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE LfFC""�" <br /> MARK ONLY ❑ I NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> YCCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> -77ry 94- OCPi9qwNv A t k P <br /> ADDRESS NEAREST CROS9 STREET ✓ bMMO 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ WFRAIATIIXI 0 LOGLL-AGENCY ❑ FEDEPALAGENLY <br /> -� ❑ INDIVIDU.4 0 COINTYAGENCY <br /> CIN NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA 9s�s <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ d PROCESSOR EPA ID MRESERVATION or - M of HIS SI <br /> F-] 1 GAS STATION ❑ 3 FARM ❑ <br /> 5 OTHER TRUST LANDS ❑ AT THIS STE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE 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 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. 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 /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ❑ Ill. ❑ <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 w JURISDICTION A AGENCY k FACILITY ID M S of TANKS M SITE <br /> I / /L <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE M WITH AREA CODE <br /> 33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X IT ICT CODE BUSINESS PLAN FILED DATE FI/LED,q <br /> 23 . `6fl 3y�' YES NO Ib 11 <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M <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. L, <br /> FORMA(3-2-88) . • � r�1 <br />