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STATE OF CALIFORNIP WATER RESOURCES CONTRAOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE 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 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N/ g <br /> ADDRESS NEAREST CROSS STREET ✓Box m,WFPR 0 PARTNERSHIP ❑ KATE AGENCY <br /> ❑ MIDI <br /> Cl LOCAL AGENCY 0 FEDERALAGENCY <br /> l� DNIDI 0 COUNTY-AGENCY <br /> CITY NAMEO�C STATE ZA CODE SITE PHONE#,WITH AREA CODE <br /> /jc ons CA 53�0 <br /> TYPE OF BUSINESS ❑ p DI RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # _ #o1 TANK's <br /> ❑ 1 GAS STATION FARM <br /> ❑ 5 OTHER TRUSTLANDSATION of ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#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 ^ 4j CARE OF ADDRESS INFORMATION <br /> Lam/ C. <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to i,dicat. ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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: L II. F-1 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 If AGENCY# FACILITY ID# At of TANKS at SITE <br /> EM = = 1 1 111101 -7101 <br /> CURRENT LOCAAL�L GGE^JNCCY FA ILITY D# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1/ 1` <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DA E FILED <br /> (� a YES NO �— <br /> CHECK/M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> r 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 /> WII FORM A(3-2-88) 41 <br /> DATA PROCESSING COPY <br />