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STATE OF CALIFORNIP WATER RESOURCES CONTROOOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �rA ;gym <br /> SITE FACILITY/SITE, INFORMATION and/orPERMIT APPLICATION / o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE �,�_p,n> <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 121,5 CHANGE OF INFORMATIONSED PERMANENTLY CLO SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) F+ <br /> FACILITY/S TE AME CARE OF ADDRESS INFORMATION N <br /> N 7-P- <br /> ADDRESS <br /> NEAREST CROSS STREET ✓BOF Ia rd-l' <br /> ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑�QpAPORATION ❑ LOCAL ❑ FEDERAL AGENCY <br /> Y�NDIVIDUAL ❑ CpUN1YAGENGV <br /> CITY NAME STATE ZIP ODE SITE PHONE ft,WITH AREA CODE <br /> HallzC` CA <br /> TYPE OF BUSINESS: [:] p DIS OR ❑ 4 PROCESSOR ✓BOx it INDIAN EPA ID a <br /> ❑ 1 GAS STATION FARM [:] 5 OTHER ORESERVATION or ❑ R of TANK's / <br /> TRUST LANDS A7 THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k 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'mNicale ❑ PARTNERSHIP ❑ STATEAGENCYOPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCYNDIVIDUAL 11COUNTY-AGENCY <br /> CITY NAME STAT ZIP ODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET AD ES v <br /> ✓Rax lo,nocate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> CITU NAME <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> .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. it. ❑ 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 S,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY IDR Ar of TANKS at SITE <br /> O 7 <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE R WITH AREA CODE <br /> E r <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE ENSUSTRACTR SUPERVISOR-DISTRICT CODE BUSINESYPLAN❑FILED NO ❑ DATA FIL ^ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If <br /> BY: <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. <br /> WFORM A(3-2-88) <br /> 0 DATA PROCESSING COPY ' <br />