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STATE OF CALIFQRN* . <br /> WATER RESOURCES CONTRBpARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA TY/SITE ' 1 <br /> c,L��ORN�P- <br /> MARK ONLY ❑ 1 NEW PERMIT E] 3 RENEWAL PERMIT <br /> ONE ITEM CHANGE O�INFORMATION <br /> 7 PERMANENTLY CLOSED SITE2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARCLOSURE <br /> L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> /'-�/J NEAREST CROSS STREET ✓Bo u�ticale ❑ PARTNERSHIP <br /> JJ (� ❑ STATE-AGENCY <br /> CITY NAME ORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Q INDIVIDUAL Q COUNTY-AGENLY <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR �4 E&OR ✓Box if INDIAN EPA ID pA L <br /> El 1 GAS STATION Ej 3 FARM 5 OTHER RESERVATION cr <br /> TRUST LANDS Er l—� M of TANK'e <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE 1 <br /> DAYS. NAME(LAST,RAsr) EMERGENCY CONTACT PERSON(SECONDARY) <br /> � j PHONE R WITH AREA CODE DAYS: NAME{LAST,FdRST) <br /> ,�/` , ( <br /> '/J"�'''') <br /> k PHONE H WITH AREACODE <br /> NIGHTS; NAME(LAS ,FIR57) PHONE WITH AREA CODE NIGHTS: L'"y�NAME{LAST,FIRST) � ' /1" <br /> PHONE#f WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> ��.. CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓BOX to indicate Q PARTNERSHIP ❑ STATE-AGENCY <br /> CITY NAME - ❑ CORPORATION Q LOCAL-AGENCY ❑ STATE-AGENCY <br /> Q INDIVIDUAL Q COUNTY-AGENCY <br /> STATE ZIP CODE PHONE q,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING Or STREET ADDRESS <br /> ✓BOX to indicate ❑ PARTNERSHIP Q STATE-AGENCY <br /> ❑ CORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME Q INDIVIDUAL ❑ COUNTY-AGENCY <br /> 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: I. <br /> W. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDTO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORR�.. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY 10# #Of TANKS at SITE <br /> CURRENT LOCAL AGENC FACILfTY ID# <br /> C00APPROVED BY NAME PHONE#WITH AREA CODE <br /> E1RIMI7 NUMBER `TL <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 'FON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE <br /> - _ J) BUSINESS PLAN FILED DATE FILED S [3 NO © <br /> p <br /> (J .a— a O <br /> PERMIT AMOUNT SURCHARGE AMOU T <br /> FEE CODE RECEIPT# <br /> BY: <br /> 'T BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 0 DATA PROCESSING COPY 9 5 <br />