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r,....,. <br /> STATE OF CALIFORNI11 WATER RESOURCES CONTRISOARD <br /> FORM 'A':SITE UNDERGROUND STORAGE TANK PROGRAM <br /> G FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 ' CHANGE OF INFORMATION 7 PERM NTLY LOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE <br /> I'. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1 <br /> FAC ITV/SITE NAME CARE OF ADDRESS INFORMATION <br /> I <br /> NEAR ST OR S STREET ✓ rV <br /> CORK)RATIe ❑ PAAALASAIP ❑ FSTATEDE GENcv � <br /> i ❑ coAvoRAnoN ❑ LocA�Accrvcv ❑ EEOEAA�A r � <br /> CITY NA ❑ INDIVIDDAL ❑ co i n nGENGr <br /> STATE ZIP CODE SITE PHONE# WITH AREA CODE I"'� <br /> J CA ��0 > <br /> TYPE OF BUSINESS: 2 DISTRIBUTo 4 FROCEBSOA ✓BO%if INDIAN EPA ID # <br /> 0 1 GAS STATION 3 FARM ®5 OTHER RESERVATION orTRUST LANDS /G❑ /�!Q AT THIS SITE <br /> #oi7ANKB <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAMU_YKE(LAST FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> {II PHONE q WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST,4 I PHONE#WITH EA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NI <br /> ,4 <br /> L ! xV1 r <br /> CARVEADDRESS <br /> DtoDRinErJSicSatIeNF ATIO <br /> MAGSTRE DRESS LJ <br /> PARTNERSHIP 11 STATE-AGENCY <br /> ikCCRPORATION <br /> qRTNERSHIPiiCORPORATION 11 LOCAL AGENCY 11L <br /> FEDERAL-AGENCY11 <br /> INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME A STATE ZIP CODE PHONE#,WITH AREA CODE <br /> in hCtsco 9Y�o <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> N E CAq,(D`DRESS INFCR TIDN <br /> MAIL G STLAIOIDR�FSSt ✓Box to indicAte ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ F D RA ENCY <br /> CI NA <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STAT ZIP DE PHONE 1.WITH AREA CODE <br /> S <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. 11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, I S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID k #of TANKS el SITE <br /> .= o / <br /> CURRENT LOCA AGE CY F CILITY ID N APPROVED BY NAME <br /> PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVIS R-DIST ICT CODE BUSINESS PLAN FILED <br /> /� DATE FILED <br /> CL2-3r YES NO _ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> 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 /> FORM A(3-2-88) <br /> 0 DATA PROCESSING COPY 44. ws <br />