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STATE OF CALIFORNIA WATER RESOURCES CONTRAOARD /r's�^�•� ..".e..'� <br /> gE P�.•OFA T"' <br /> FORM `A': l; <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - ,z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cgk"oR 'pi <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1�s(l CJV <br /> v C) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C •`e'A_A � ❑ INDIVIDUAL 13 <br /> ❑ COUNTYAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP C DE SITE PHONE#,WITH AREA CODE <br /> LciCASayl� a�9 333 w <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM b5 OTHER RESERVATION or ❑ �� #of O <br /> TRUST LANDS AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> afi I Il c r209 `-) S - _- <br /> NIGHTS: NAME(LAST,FIRST) I PHONE It 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 /> 1 f f Lam 1----_ <br /> MAILING or`STREET DRESS ✓Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> 1 3 S- m El 11 <br /> 1 -� OCAL-AGENCY ❑ FEDERAL-AGENCY <br /> •�--� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME._A STATE a5i <br /> PHONE#,WITH AREA CODE <br /> o c `-� u a o�I 33 3(P1`{() <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: 1. ❑ 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 /> El—al I I I I I I I I LO 1 0 1 c;! I c,)- FT- F-1 Lo I oT_o F I <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> L41 1 YES ❑ NO ❑ CC L3 I I 2_ d <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 0 <br /> `d FORMA(3-2-88) � • <br /> DATA PROCESSING COPY -� <br />