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STATE OF CALIFORNO WATER RESOURCES CONTRIBOARD <br /> FORM 'A': ,. \i <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } ' <br /> C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT L_j 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> J' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) c <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS _ w6cJ <br /> INEARESTOSS STREET ✓SA to inaiaate ❑ PARTNERSHIP ❑ STATE AGENCYCORPORATNDIVIOUA(IGN ❑8'O(✓ryaGE ❑ FEOEAAL-AGENCYCITY NAME ZIP CODE SITE PHONE ft WITH AREA CODE 7( <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCE R ✓Box if INDIAN EPA ID # <br /> 1 GAS STATION 3 FARM THER TRUSRYANDS ESEATION or ❑ p of TANKAT THIS SITE'a <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE/k WITH AREA CODE DAYS'. NAME(LAST.HHS H PHONE k WITH AREA CODE <br /> �✓ �0� k`33 l/ G/ ,F23 l3G <br /> NIGHTS: NAME ST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST RST) PW6NE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I ✓Box to odicate ❑ VIRTNERSHIP ❑ STATEAGENCY <br /> /n ❑ CORPORATION ❑ LOC ,L�ENCY ❑ FEDERAL-AGENCY <br /> V' ❑ INDIVIDUAL 61F-trNTy-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> A� 33 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box t.,Ldicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTYAGENCYCITU 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: 1. 1:1 If. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCY k FACILITY ID K x of TANKS at SITE <br /> 0 � o � 3 <br /> CURRENT L09AL AGENCY FACILITY�D.Y— APPROVED BY NAME PHONE N WITH AREA CODE <br /> G <br /> PERMIT NUMBER PERMITAPPRwOVAAL ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTM S ERVISOR-DISTRICT CODE BUSINESSLAN❑FILED NO ❑ DATE FILED/ <br /> 3-�U (J(j <br /> CHECK M PERMIT AMOUNT SURCHARGE AM NT FEE CODE RECEIPTS Y; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> 0 DATA PROCESSING COPY • <br />