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STATE OF CALIFORNIA WATER RESOURCES CONTRO4LOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° «; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> I <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ® � <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CTI <br /> III FACILI SITE NAMFT �� CARE OF ADDRESS INFORMATION <br /> f/V« <br /> ADDRESS OZJ /x' NEAR T ROS STREET ✓BORPOORr,¢V ❑ ppmLEAGEN ❑ FEDERAGENCY <br /> ALAGEN <br /> [/ "\J �CAAPOAAl10N ❑ LOCAL Cl STATEALAGENC/ <br /> ❑ INDIVIDUAL ❑ COUNIV AGENCY <br /> CITY NAME . STATE ZIP ODE E PHO E#,WITH AREA CODE <br /> G6o> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTORD, <br /> PROCESSOR ✓Box if INDIAN EPA ID N X of TANK'# <br /> RESERVATION or / <br /> ❑ 1 GASSTATION [:] 3 FARM Lkl 5 OTHER TRUST LANDS ❑ 11/ AT THIS SITE bl <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS�A E(I-AST,FIRST) PHONE#WITH AREA CODE <br /> 3 — j 10 � <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHT$'. ME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S - o Q( R <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WIT AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF gRESS INFORMATION <br /> N )Y�� <br /> MAfior0 ER IS <br /> ticate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> PCORoOnRATION <br /> ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> `•� ` J V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME 1 STATEZIP CODE <br /> 11A PHONE k,WI H AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS CC G(J <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III. 10 <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 X JURISDICTION X AGENCY# FACILITY ID X X of TANKS at SITE <br /> ® = n s d a a <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NA E PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPRO AL DA PERMIT EXPIRATION DATE <br /> t) I <br /> LOCATION CODE CENSUS TRACT#z SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �,8Vyz <br /> YES <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. <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) <br /> DATA PROCESSING COPY <br />