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_ _.._.. I d T . <br /> STATE OF CALIFORNO WATER RESOURCES CONTISBOARD /. �F <br /> FORM `A': � <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 5 <br /> MARK ONLY F__11 NEW PERMIT ' 3 RENEWAL PERMITC. •` 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'+ <br /> ONE ITEM E]2 INTERIM PERMIT 4 AMENDED PEFiM1T 6 7EMPORARV SITE CLOSURE '�` )— W <br /> CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS -(MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> (3ckiD I-) Cechi C c l c, Zvcxvi —Fe ((U <br /> ADDRESS 3 NEAREST CROSS STREET I/Gm landicale El PARTNERSHIP 1:1 STATE AGENCY <br /> I Vi/Y V� CORPORATIaN ❑ LOCAL AGENCY 11 FEDERAL <br /> ❑ INDIVIDUAL ❑ COUNTr_ACENa .tRA�o <br /> CITY NAME STATE ZI/P�CODE� SITE PHONE#,WITH AREA CODE� CA gsao <br /> If of TANK's <br /> TYPE OF BUSINESS: [7 p DISTRIBUTOR 4 PROCESSOR ✓BO%iI INDIAN EPA ID # <br /> I GASSTATION �3 FARM OTHER RESERVATION or �\ AT THIS SITE <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRI ARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) r PHONE#WITH AREA CODE DAYS'. NAME(I-AST EA,FIRST) PHONE ft WITH ARCODE <br /> d oY, 0�1 t <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHT$ NAME(LAST,FIRST).. PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CIN NAME STATE ZIP CODE. PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> T ' � <br /> MAILING or STREET ADDRESS ✓Bax toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INOICATIN4 WHICH ABOVE ADDRESS SHOUlft USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALIFffifiERJURY,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# It of TANKS at SITE <br /> 3q = b O l a 3 a U C� U <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> TOCk 3a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATION CENSUS TRACT#, SUPERVISOR 01BTRICT CODE BUSINES Y$N❑FILED NG ❑ 1TE[HLED <br /> yo <br /> PERMIT AMOUNT SURCHARGE AM\OOUNT FEE CODE RECEIPT# I BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTjR MORE TANK PERMIT FORM `B'APPLICATION(S),UTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> 1 <br />