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STATE OF CALIFORNIA WATER RESOURCES CONTROL <br /> ARD a <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONZ <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y C ITE <br /> ONE ITEM E]p INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE 3 '4 <br /> e ] -4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) (a <br /> -.I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S s A 11�1' €*.- d o e No ;N', <br /> ADDRESS NEAREST CROSS STREET ✓Uov to IN ❑ PARTNERSHIP ❑ STATE AGENCY <br /> O G A ❑ TION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> O W NONIDUAL ❑ CWMRAGENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> CA fps u� <br /> TYPE OF BUSINESS: ❑ p 0 UTOR ❑ 4 PROCESSOR ✓BOX if INDIAN EPA ID k ,// n <br /> ❑ f TANK' <br /> ❑ TRUST or ❑ "4 L'G� AT THIS SITE <br /> I GAS STATION 3 FARM 6 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 5.�l3 S . <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME c! CARE OF ADDRESS INFORMATION <br /> J ,0p .T- <br /> MAILING or STREET ADDRESS ✓Box ate Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ PORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft,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 <br /> e ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ ORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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. 14�11. ❑ 111.❑ <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 N JURISDICTION N AGENCYIN FACILITY ID M N of TANKS at SITE <br /> 3y 0 000 <br /> CURRENT LO AL ENCY lj'I�/ FA TY ID APPROVED BY NAME PHONE K WITH AREA CODE <br /> PERMIT NUMBER I� L PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOTIJCODE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> t-3a3 - YES ❑ NO ❑ 34 <br /> CHECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 /> 1 I I I FORMA(32-88) <br /> \VI YYY DATA PROCESSING COPY <br />