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STATE OF CALIFORNIA WATER RESOURCES CONTRJROARD <br /> SEPI � A <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> F <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE `^�,.aa��a <br /> El <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE J-6ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 3 ry <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) A <br /> FACILITY SITENAME [NEAREST <br /> OF AODREVFORMATION <br /> —12 �' u TAiv <br /> ADDRESS CROSS STREET rlo imine ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ORATON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> CIN NAME �- INDADUAL ❑ COUNTYAGENCY <br /> A ZIPCODE�� / SI PHON p,WITH ARES=pDETYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ OCESSOR ✓Box if INDIAN D <br /> ❑ I GASSTATION ❑3 FARM 5 OTHER RESERVATION or ❑ #of TANK', <br /> TRUST LANDSAT THIS SITE , <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAMEFIRST) PHONE AREA CODE DAYS: A EILAST,FIRST) P �yWITH <br /> AREA <br /> REq�i/OD <br /> E <br /> ncbQ,efa5PrlV� (7G9) n / ./ � /6 <br /> NIGHTSNAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) J HONE#WITH AREA CODE <br /> 9/d 63f ye03 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME 4 CARADDRESS INFORMATION <br /> MAILING or STREET ADDRESSeL �� o cficate El 11STATE-AGENCY <br /> 01G`41ORATION ❑ LOCAL-AGENCY IllFEDERAL2 <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE,4 cieiw 90-V <br /> alz <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME v_,•` /� CARE OF ADDRESS INFORMATION <br /> N J <br /> MAILING or STREET ADDRESS I/Box lo,nd,cale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOJ(INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ll� If. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1t JURISDICTION N AGENCY N FACILITY ID k k of TANKS at SITE <br /> m O IG I Is <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOP-DISTRICT CODE BUSINES,P S NFILED NO ❑ ppTp FI /�Z� <br /> Ll 4 <br /> CHECK R PERMIT A OUN17 IT10 T SURCHARG AMOUNT FEE CODE RECEIPT a 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 /> FORM A 13-2-88) DATA <br /> DATA PROCESSING COPY <br />