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STATE OF CALIFORNIN' WATER RESOURCES CONTRABOARD t s Vie. <br /> FORM 'A': W <br /> UNDERGROUND STORAGE TANK PROGRAM ` " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : ;/ o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ NTERIM PERMIT p I 7 PERMANENTLY CLOSED SITE FJ <br /> ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE i N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OD <br /> CJI <br /> FACILITY/SITE NAME ^ <br /> CARE OF ADDRESS INFORMATIOry� <br /> ADDRESS 4^` <br /> 35 Q � 1 �c re NEA EST CROSS STRE T ✓Aoa 10 route ❑ PAATNEASHIP ED] <br /> SiAiEAGN <br /> J a c /, ❑ CORPORATION.�CALAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME �� ( I U ❑ INDIVIDUAL ❑ COUNTI-AGENCY <br /> 1 � ' STATE ZIP ODE SITE PHONE ql,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA o If <br /> ❑ I GASSTATION ❑ 3 FARM OTHER RESERVATION or ❑ - #of TANK's ,\ i <br /> TRUST LANDS AT THIS SITE (J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE OAVS'. NAME(LAST,FIRST) <br /> L,� PHONEp WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) I LV l•`�(f PHONE If WITH AREA CODE) NIGHTS: NAME(LAST FIRST( <br /> PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ; C_EO <br /> + CARE OF ADDRESS INFORMATION <br /> odl � k� �- <br /> MAILING an NG or STREET A DRESS /n� G ✓Box to'mNicale 0 PARTNERSHIP <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME llti� C0 omINDIVIDUAL ❑ COUNTYAGENCY <br /> 0 FEDERAL-AGENCY <br /> p STATE ZIP D PHONE II,WITH AREA CODE <br /> 209 333t07-/0 <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 STATE <br /> EFEDERAL-ENCY <br /> CITYNAME ❑ INDIVIDUAL 0 COUNTY-AGENCY AGENCY <br /> 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. ❑ II. 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# AGENCY# FACILITY ID It <br /> #o <br /> U f TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME <br /> I /ti O PHONE#WITH AREA CODE <br /> PERMIT NUMBER lJ `/`JPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Y Ou YES NO IUD <br /> - Ll <br /> 1 .G(1 <br /> CHEIT " <br /> CK# PER AMOUNT SURCHARGE AMOUNT FEE CODE I 0 6 <br /> RECEIPT BY: <br /> I THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> \vvl FORM A(3p-80) <br /> DATA PROCESSING COPY • <br />