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'- <br /> ycP� Tti� <br /> STATE OF CALIFORNIS WATER RESOURCES CONTRO OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = ` gym <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1y� <br /> qa, <br /> COMPLETE THIS FORM FOR EACH FAC ITY/SITE C4l!FOFYP <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREQ0 — F-& <br /> —4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) "P <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to intllcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / / r I ,III ❑ CORPORATION ❑ CO JNTAGENCY ❑ FEDERAi AGENC/ <br /> ❑ INDIVIDUAL ❑ CbUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE E PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ d PROCESSOR --/Box if INDIAN EPA ID p —^y� #of TANK`s <br /> RESER' GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS of ❑ r QV`.ti� AT THIS SITE <br /> ATIOI <br /> t v I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS- NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ��t A-4 04 20 2- U 71� Y`-f -12-1 <br /> NIGHTS: NA E(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(I AST.FIRST) HONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> -' Z Smc <br /> MAILING or STREET ADDRESS ✓Ba indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Tl�� V1 3NDIVOLIAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEP6q) <br /> NE#.WITH AREA CODE <br /> ( - ,IZCoI <br /> 111. TANK 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 /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY _ <br /> CITY NAME STATE ZIP CODE PHONE H,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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> [Ci <br /> OUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> NT LOCAL AGENCY FACILITY ID M APPROVED BFNAME <br /> PHONE k WITH AREA CODE <br /> ASI ISL s I <br /> T NUMBER PERMIT APPROVAL DATE RATIONDATE <br /> TION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �/G <br /> 9 2 3. _D ,(�� YES NO ❑ �) —b ! <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />