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1.or <br /> STATE OF CALIFORNIAWATER RESOURCES CONTROSOARD 5" <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> (/ COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— MUST BE COMPLETED) <br /> FACILITY/SITE NAMEhNt& CARE OF ADDRESS INFORMATION <br /> 14(. /34f 0 � eMFnl <br /> ADDRESS W✓n NEAREST CfiJ1S$STREET _ ❑ CW� 13 11PAS DO 11FMk AGDCr <br /> I//v-�_•'[•/�✓F- ❑ INDMWAL ❑ ODUNIY AG&GY <br /> CITY NAME ✓ l%(p STATCA ZIP CODE SITE PHONE q,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓BOX V INDIAN EPA IID 0 / S If of <br /> ❑ 1 GAB STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS or ❑ ��71/D`��/ �0�� AT HIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CAPE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to molicale D PARTNERSHIP - D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME 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. ❑ HL❑ <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 N AGENCY N FACILITY ID N It of TANKS at SITE <br /> M 1010 = v <br /> CURRENT LOCAL 11gE'N^Y FAILI# APPROVED BY NAME PHONE 4 WRIT AREA CODE <br /> PERMIT NUMBER A S PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTSUPERVISOR-018TIlq CODE BUSINESS PLAN❑FILED ❑ DATE FILED — �` <br /> r(j/3 QVO LN YES NO <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <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 /> `ORM A(3-2-88) <br /> ,Y�1JI � <br />