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STATE OF CALIFORNO WATER RESOURCES CONTRORIOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM z <br /> �,q l 10 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION „QaNP <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE � <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PER ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Li Uji pies <br /> je I ✓ r.m lydlrsfe ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ADDRESS NEAREST CROSS STREET SCRYRATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> Vq / /V�� ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE POHONE p,WITH AREA CODE <br /> S C ve—OCA (Sy 3 5 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR4 PROCESSOR -/Box if INDIAN EPA ID # #of TANK's <br /> ❑ <br /> D5 OOTHER RESERVATION or 1-1AT THIS SITE O <br /> ❑ 1 GASSTATION [:] 3 FARM ✓ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE ft WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to Intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p.WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CXECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 /> COUNTY N JURISDICTION# AGENCY M FACILITY ID# a of TANKS at SITE <br /> APPROVED BY NAME PHONE a WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID a a a 3 <br /> /_'r[ ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> LOCATIIOON CODE CENSUS TRACT MO SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> L/C7 3 oa !U]l YES � NO ❑ t <br /> RECEIPT# BY: i <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE .P. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B`APPLICATIONO), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> '/`N(1111 DATA PROCESSING COPY <br />