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c. <br /> STATE OF CALIFORNI.0 WATER RESOURCES CONTROROARD f.`� . <br /> Z TSS <br /> FORM `A': u " <br /> UNDERGROUND STORAGE TANK PROGRAM x ' o <br /> SITE FACILITY/SITE, INFORMATION and/Or PERMIT APPLICATION <br /> C COMPLETE THIS FORMA FOR EACH FACILITY/SITE `4L 111 Rll`P <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE .j <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE '77 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION O <br /> / Gl <br /> ADDRESS NEAREST CROSS STREET */80001 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MCI! ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> + ' + �� W -r'4 C^A4M ❑ INDIVIDUAL ❑ COUNtt-AGENCY <br /> CITY NAME n STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> R r CA 53( L�� -/?L <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 Pfl00ESSOR ✓Box if TION o EPA ID p <br /> GAS STATION 3 FARM 5 OTHER RESERVATION or N of TANK'a .--, <br /> ❑ ❑ TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIHST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 12- ❑ INDIVIDUAL El COUNTY-AGENCY <br /> CITY AM STATE ZIODE PHONE#,WITH AREA CODE <br /> C <br /> R I ' <br /> Ill. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME q CARE OF ADDRESS INFORMATION <br /> T. as <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNEHSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ II. III- ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 It APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> +r' r o ''2 G YES ❑ NO ❑ L2 �/5II (')j� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST R MORE TANK PERMIT FORM pB'APPLICATIII UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-85) <br /> DATA PROCESSING COPY <br />