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___ _ -... -.:. :.-€_--•-.r�:�....-.-.�.z-.�mor. �..-... ...,...-.��...� �• �fnr _ _ , � . . .. g �.,, _ p <br /> STATE OF CALIFORNIAWATER RESOURCES CONTROMOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u y� 0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY el'NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 P LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 4�61 <br /> N <br /> FACILITY/SITE NAME CARE OF A DRESS INFORMATION <br /> ADDRESS / NEAREST CROSS STREET ,.✓ tnindirale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C = J 1 � �r., I� 4< CORPORATION ❑ LOCAL-AGENGY ❑ FEDERAL-AGENCY <br /> [V W (J ❑ INDIVIDUAL ❑ COONTY-AGENCY <br /> CITY NAME STATE ZIP CODESITE PH E 4,WITH AREA CODE <br /> 0c.Pez�40�ucCA �? 3 "I Za Z <br /> TYPE OF BUSINESS: F—VDISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID �JA #of TANK's <br /> ❑ GAS STATION 9 FARMS OTHER RESERVATION or AT THIS SITE <br /> ❑ u TRUSTLANDS ❑ i✓I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LLAST,FI T) PHONE 9 WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'„ NAME(LA T,FIRST) PHONE q WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> t/ �'/`�Q04 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMEA �,, Q CARE OF ADDRESS INFORMATION <br /> ��O <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> ElCORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS a (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 11 LOCAL-AGENCY ElFEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. 11. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 " o I o o <br /> CURRENT LOCAL A-GJE�NCY FACILITY ID II APPROVED BY NAM `y.� PHONE K WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE P' MIT EXPIRATION DATE <br /> j Z_ <br /> LOCATION CODE CENSUS TRACT 0 h SUPERVI5 -DISTR CT CODE BUSINESS PLAN FILED DATE F ED <br /> AFL L YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <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(3-2-88) <br /> DATA PROCESSING COPY <br />