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STATE OF CALIFORNIP WATER RESOURCES CONTRARIOARD <br /> f ) ri <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PER IT APPLICATION <br /> C� COMPLETE THIS FORM FOR EACH FA TY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C 3 - <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> k <br /> ADDRESS NEAREST CROSS STREET ✓Boren maple ❑ PARTNEISHIP ❑ STATE AGDO <br /> �7 ❑ CORPORATION ❑ LOCAL-AGDAN ❑ FJ)EML-AGENCY <br /> ❑ INOMOUAL ❑ 00UNTYAGE10 <br /> CITY NAME ,E /4, STATE ZIP CODE SITE PHONE#,WITH AREA CODE S C cc si— AR <br /> / <br /> TYPE OF BUSINESS: ❑2 DIMIBUTOR ❑4 "SOR ✓BOX If INDIAN EPA 0 pA ��3 z� C �ry S J 3 i9 vg- <br /> ❑ 1 GAS STATION ❑3 FARM S OTHEA TRUSTYLANDS o If❑ AT THIS SITE AT THIS SITE O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NAME <br /> NIGHTS: NAME( ST,FIRST) PHONE N WITH AREA CODE NI TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION - <br /> /5cC •"AE.. ee S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CA RE OF ADDRESS INFORMATION <br /> SGr _.t.c' <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOR INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 4� "' U 'll.❑ <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 /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME <br /> 0c �2PHONE#WITH AREA CODE <br /> � <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 3 3 1-?- (. YES ❑ NO \ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 0- <br /> G'a 7�yi 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISACHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) L 6 <br /> _��� -� • DATA PROCESSING COPY <br /> d– <br />