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STATE OF CALIFORNO WATER RESOURCES CONTRALARp <br /> FORM `A': <br /> �. . ; <br /> SITE <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION <br /> 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT <br /> ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) t <br /> FACILITY/SITE AME I <br /> /�� I CAR OF ADDRESS INFORMATION II I <br /> ADDRESS O vt C SOC.( r I O W O Ld <br /> ^� I IST '/ NEAREST CROSS STREET ✓aorta iMiwte 0 PARTNERSHIP 0 STATEAGENCY <br /> e� U I ' ye 0 CORPOMTION 0 LOCAL.AGENCY FEOERALA NCY <br /> CITU NAME ❑ INOMINIAL ❑ COGNIY AGENCY �, <br /> Sr V—,^ STATE ZIP(�Jf z T SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS -r 1- I CA 'I��V I O(3 � , / N. <br /> ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓BOX if INDIAN EPA IDN <br /> ❑ I GAB STATION ❑ 3 FARM �-O{BER RESERVATION Or M of TANK's <br /> TRUST LANDS ❑ "—�— 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) <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> y� CARE OF ADDRESS INFORMATION <br /> 1 lLCU 1� <br /> MAILING Or STREET ADDRESS <br /> ✓BOX 10 intlicale ❑ PgRTNERSHIP DS <br /> El CORPORATION TATEAGENCY❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY, <br /> CITU NAME El INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box toIndicate 0 PARTNERSHIP 0.STATE-AGENCY❑ <br /> CORPORATION Cl LOCAL-AGENCY ElFEDERAL-AGENCYCITY NAME ❑ INDIVIDUAL D COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREACODE <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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY M <br /> FACILITY IDN Mol TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION COE CENSUS TRACT N SUPERVISOR-DISTRICT CODE <br /> BUSINESS PLAN FILED DA7_F�1FLED <br /> VES Cl NO <br /> CNECKN PERMIT AMOUNT SURCHARGE AMOUNT <br /> FEE CODE RECEIPT M C <br /> THIS FORM MUST BE ACCOMPANIED BYAT LEASTW MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. C <br /> DATA PROCESSING COPY • <br /> , <br />