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....";"EI e.....,..r„r.„r..�....-r-.._. �'4CLIM- _, �_..yP •- <br /> STATE OF CALIFORNIV WATER RESOURCESCONTRIBOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �, go <br /> COMPLETE THIS FORM FOR EACH74— F ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1-& <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> )_& <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 11i <br /> C71 <br /> FAC IL N/SITE NAME CARE OF ADDRESS INFORMATION <br /> / <br /> ADDRESS ,� / NEAREST CROSS STREET I/30x toi d.N ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 0 / )( /r�/��-/J L7 RA ION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> / ( ���^- INDIVIDUAL ❑ COUNNAGENCY <br /> CITY NAME STATE ZI CODE SITE PHONE#,WITH AREA CODE <br /> Mme//CeC� CA S <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 r At of TANK's <br /> PROCESSOR Bout INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ ARM ❑ SOTHER TRAT <br /> USTVLANDSO ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#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#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ocicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,I,dcate ❑ PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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: I. ❑ it. ❑ Ill. ❑ <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 R JURISDICTION R AGENCY R FACILITY ID N If of TANKS at SITE <br /> l <br /> CURRENT LOCAL AGENCY FACI ITYJQ N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER L�,/7� ((�C/J' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIDgC DE CENSUS TRN SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ DATE FILE/-- <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# C BY: <br /> THISFORM MUSTBEACCOMPANIED BYATLEAST(I)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OFSITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />