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-, vme•-.-rasgppscy'#tlwrypQRrF^'r:..atr._:r... -_- -,. ea... <br /> St F`�uu.i'.Mf <br /> STATE OF CALIFORNIe WATER RESOURCES CONTROLtOARD <br /> FORM 'A'- UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> T _ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK-O-fN-L�Y ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ERMANENT�SED SITE W <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE p�pp <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) G� <br /> FACILITY/SITE NAME h1� CARE OF ADDRESS INFORMATION <br /> Od i n. <br /> _.f i S`F cL( b1l rcARES STREET <br /> ' NEAREST CROSS STREET ✓Da loiMrak ❑ PAATNERiHIP ❑ STATE AGENCY <br /> ADDR Cl CDAP0R1PGN ❑ lOg4AGENCi ❑ FEDBVL-AGEt1GY <br /> P' ^ e i ❑ INDNIDL ❑ CON ADEN Y <br /> C./�-K_/ STATE ZIP CODE SITE PHONE 11,WITH AREA CODE <br /> CITY NAME ^ CA <br /> TYPE OF BUSINESS: C—JV'2ADI`STNIBUiOR 4 PflOCESSOR ✓Box if INDIAN EPA I° a - If TANK'# <br /> ❑ 5 OTHER RESERVATION or ❑ AT THIS SITE <br /> ❑1 GASSTATION ❑ 3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME p\ <br /> MAILING MSTREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY \ <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE 21P CODE PHONE p.WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 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: I. ❑ it. ❑ St.❑ <br /> 71 <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# JURISDICTION R AGENCY R FACILITY ID If a of�TANKS <br /> 'yyat SITE <br /> ( <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-018 TAICT CODE BUSINESSPLAN FILED DATE ICED <br /> ( YES 3 NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> ORMA(3-2-88) <br /> r {�� ` DATA PROCESSING COPY �� <br />