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5 <br /> STATE OF CALIFORNI0 WATER RESOURCES CONTRAOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION p° z <br /> cCOMPLETE THIS FORM FOR EACH FACILITY/SITE4"Fee I <br /> MARK ONLY El i NEW PERMIT ❑3 RENEWAL PERMIT �5 <br /> 2 INTERIM PERMIT CHANGE OF INFORMATION <br /> ONE ITEM ❑ ❑ ❑ T PERMANENTLY CLOSED SITE F-164 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> 11 <br /> CARE OF ADDREfCe)SS INFORMATION�Ij, ,[J <br /> ADDRESS F' r"`A) <br /> ..,./ NEAREST)CR068 STREET ✓Rpe to iMi-lit 0 PARTNERSHIP 0 STATEAGENCI <br /> L(FICC �� ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGEND' <br /> CITY NAME INDIVIDUAL 0 COUNTYRGEND <br /> e^ STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA o 6 6 <br /> TYPEOFBUSINESS: ❑ p DISTRIBUTOR El PROCESSOR ✓ <br /> Box If INDIAN EPA ID n ~ <br /> El GASSTATION ❑ 3 FARM OTHER RESERVLA ION or ❑ - #o1TANK'e <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST), ' / PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> /n'x�L/. PHONE tt WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) I/� r ��N <br /> (� 5I PHONE q WITH AREA CODE NI rygM,E(LASE FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION 81 ADDRESS - (MUST BE COMPLETED) <br /> OW) <br /> a el e <br /> NA CARE OF ADDRESS INFORMATION <br /> MAILINGor STREET ADDRE/S.S� ✓Box to indicate ❑ PARTNERSHIP <br /> 11 STATE-AGENCY <br /> I 0 CORPORATION ❑ LOCALAGENCY0 FEDERALAGENCY <br /> CI <br /> El INDIVIDUATE AGENCY <br /> TU E STATE ZIP CODE COUNTY- <br /> C PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION 81 ADDRESS - (MUST BE COMPLETED) 5 <br /> NAME CARE OF ADDRESS INFORMATION <br /> US I I <br /> MAILING or STREET ADDRES ✓Box to indicate 0 PARTNERSHIP <br /> ❑ CORPORATION13 STATE-AGENCY <br /> 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCYAGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE k,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 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYTI JURISDICTION N AGENCY N FACILITY ID# <br /> N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME <br /> PHONE N WITH AREA`ODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> 1 Z_3 /1 � 1 DA( FIE D C-4 <br /> I CD .. v YES NO 1� <br /> CNECKN PERMIT AMOUNT SURCHApOE AMOUNT FEE CODE <br /> RECEIPT# 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.C <br /> FORM A(3-2-88) <br /> iDATA PROCESSING COPY <br /> L/ <br />