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4?STATE OF CALIFORN1 WATER RESOURCES CONTROL OARD /5`" �` 'rM1Asa <br /> FORM `A°. a� <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE y <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT Lam-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE L1 <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> •C�#A'S� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION wyw,y, <br /> IMI <br /> ADDRESS NEAREST CROSS STREET ✓Ba 0 mdicale 0 PARTNERSHIP 0 STATE AGENCY 0 <br /> CORPORATION O LOCAL AGENCY 13fEf1ERAL AGENCY <br /> 0 INDIVIDUAL <br /> CITY NAME STATESITE PHONE N.WITH AREA CODE <br /> CA ZIP CODE <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> TESERVLANDS I or ❑ #of TANK'e <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHERAT THIS SITE <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 /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 Indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ I. ❑ 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# JURISDICTION# AGENCY# FACILITY ID IF #of TANKS BI SITE <br /> z. z <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [2LPERMIT <br /> NSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO ❑ DATE FI lj D <br /> 23, 3z /f <br /> AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST E ACCOMPANIED BY AT ST(1)OR TANK PERMIT FORM B'APPLICATION(S), UNLESS HIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 410 <br />