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STATE OF CALIFORNIN WATER RESOURCESCONTROARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE F' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER SED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 'J <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) O <br /> FACILITY SITE NAME ^ - CARE OF IDDRESS INFORMATION <br /> ADDR /{ J ///��� NEAARR.ES�CROSSS STREET ✓Bn,b Y6iwb ❑ PAATNBsP ❑ FATE.AGDO <br /> d "W/� ! ❑ 008POMINDIADUAL01 11❑ Cg1NIYAGBqGY-AGENC! GER4 AGENCY <br /> CITY N STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> �e CA <br /> jS`Zas 3/ - - <br /> TYPE OF BUSINESS', ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> GAS STATION ❑ 3FARM ❑50THER TRUSRESETYLANDS or of TANICS <br /> ❑ A ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) • PHONE 0 WITH AREA CODE DAYS: NAME(LAST.FIRST) ,PHONE N WITH AREA CODE <br /> �b A S <br /> NIGHTS: NAME(LAST,FIRST) ONE p WITH AREA CODE NIFyTS: NAME(LAST,FIRST) �/-HONE M WITH AREA CODE <br /> 3 1A S G A //A <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> AzNAMESCARE 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 k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME SACARE 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 It,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. Er- 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION a AGENCY N FACILITY ID h B of TANKS at SITE <br /> O o / & I 00 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED By NA)RE PHONE N WITH AREA CODE <br /> -Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAChT O SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE <br /> FV YES ❑ NO 14A /,1 7ir <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. <br /> FORMA(3-2-68) 1 � �- <br /> �', 40 DATA PROCESSING COPY <br />