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STATE OF CALIFORN19 WATER RESOURCES <br /> CONTROS <br /> OARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM 'moo <br /> SITE /2 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�FO RSP <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE i� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 40-3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) "j <br /> FACILITY/SITE NAME e,t 6t/I-ql A,', Of I Ve,,— CARE OF ADDRESS INFORMATION 00 <br /> 3/D O 9— Vic.-f- C4/C-- <br /> ADDRESS NEAREST CROSS STREET ✓Boa to indirale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> u k ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME / STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> �- [-, CA <br /> TYPE OF BUSINESS: ❑ 2 DIST IBUTOR F-14 PROCESSOR -/Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> E] i GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST)) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE <br /> L <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> a ��C `C C�� ❑ C ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> -/ J DIVIDUAL ❑ 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = I 1 11 1 1 1 1 1 1 [�T/ _--2- 1 / 171 <br /> f <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> QL/ VC/� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �l I �r ?3 ;�-3 3 <br /> CHECK# PERMIT AM SURCHARGE MO N T FEE CODE YES ❑RECEIPTI#O [:] 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 /> \i\ FORM A(3-2-88) <br /> `v\ � DATA PROCESSING COPY 0 <br />