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STATE OF CALIFORNIP WATER RESOURCES CONTRAOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `® . <br /> G COMPLETE THIS FORM FOR EACH F CILITY/SITE o " <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E2/5CHANGE OF INFORMATION ❑ 7 PERM Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION <br /> a fl S <br /> ADDRESS ^�� / (T\ NEAREST CROSS STF�EET ✓Bwb Mid¢ ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATOR Cl LOCAL AGENCY ❑ FEpERAL.AGENCY <br /> tt <br /> ❑ NomouAL ❑ GauxnACB+cr <br /> CITY NAME STAT21P CODESITE PHONE N,WITH AREA CODE <br /> S rZ� <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCE$SOfl ✓Box if INDIAN EPA ID 0 <br /> RESERVATION or M of TANK' <br /> ❑ 1 GAS STATION ❑ 3 FARM HER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORM ION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to,ftcwe 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — UST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to irrtlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STA ZIP CODE PHONE A,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NO (CATION AND BILLING: I. E] If. E] Ill.E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BES F MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACILITY ID R M of TANKS at SITE <br /> D 1363 Dada <br /> CURRENU <br /> NT LO <br /> L 11GENCY FACILITY ID M APPROVED BY NAME PHONE R WITH AREA CODE <br /> PERMIT NUMBER /7G PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C`�ODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> l� t D a YES NO 31&1efo <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y <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 13-2-8BI <br />