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STATE OF CALIFORN IP WATER RESOURCES CONTROBOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITELITY/SITE, INFORMATION and/or PERMIT APPLICATION Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT Ll4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORM ION <br /> ,, 2ro q SP(Y>/cc <br /> ADDRESS NEARE TCROSS STREET 1/8.to iidiuiI, 0 PARTNERSHIP ❑ STATE AGENCY <br /> / El CORPORATION 0 LOCAL AGENCY 0 FEDEAALAGENCY <br /> 64/01 ,p/ v 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NA/ME , STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> t Is" CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID IT N of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST YLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE if 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 indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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 indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRES <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOUL D FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY O ERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE)) 4 DATE <br /> V� <br /> LOCAL AGENCY USE QNkA <br /> COUNTY q ON k AGENCY k FACILITY ID R M of TANKS at SITE <br /> m = = 10 10y .2- 3 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> C /5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> E CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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) Lp <br /> ( , I,/ �o�D � DATA PROCESSING COPY 0 <br />