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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD <br /> Je[ '••h <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�FOR�P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACIL ITE E , CA/R(E,IOgADDRESSINFORMATION <br /> ADDRE S Z / NEAREST C O'S STREET omdicate ❑ PARTNERSHIP "SAT CY� CORPORATION ❑ LOUNTY-ENCYNCY <br /> f ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZI ODE ITE PH NE#,WITH AREA CODE <br /> CA <br /> "fuk_o <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #cl TANK'a <br /> [el—GAS STATION 3 FARM 5 OTHER TRUST LANDS ❑ 0— AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST, RST) PHONE#WITH AREA CODE DAYS; NAME(LAST,FIRST) P O E#WITH AREA CODE <br /> NIGHTS NAME jAFmTriRSTj - I PHONE#WITH AREA CODE NIG TS. NAME(LAST,FIRST) P�J�NE 9 WITH AREA CODE <br /> ptj <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE <br /> (B7E COMPLETED) d <br /> NAM CARE 9V ADDRESS INFORMATION <br /> IL/J,4 <br /> MAILING or. TREET A ESS ✓Box to indicaie ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> p� ❑ CORPORATION ❑ LOCAL-AGENCYDEflA - GFNCY <br /> a-(J ❑ INDIVIDUAL <br /> El <br /> CITY NAMELO <br /> STA ZIP ZIP S�qi PHONE ITH ARFA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM�,� �y/ j � CARE O ADDRESS INFORMATION <br /> r-11 <br /> G or STREET ADDRESS =(][,1�,'�- �� ✓ x to irdicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ff CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CI NAM STATE ZIP� �I HANE#,WITH AREA CODEff11' v <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. ❑ II. ❑ 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# #of TANKS at SITE <br /> 0111CSO <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY ME PHONE#WITH AREA CODE <br /> d 1/ 0 <br /> PERMIT NUMBER PERMIT APP OVTE PE MIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT#. 'SU RVISOR-DISTRICT CODE BUSINESS PLAN FILED - DATE FILED <br /> YES NO � <br /> CHECK# PERMIT AM UNT SUR HARD AMOUNT FEE CODE RECEIPT# BY: <br /> _t <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 /> FORMA(3-2-88) 40 <br /> DATA PROCESSING COPY <br />