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STATE OF CALIFORNIP WATER RESOURCES CONTROL410ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE /� _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> V COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM OSED SITE F-+ <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) ca <br /> FACILITY/SITE NAME a CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ aWaite ❑ PAFNERSHIP ❑ STATE AGENCY <br /> CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> L `�� - C'-✓ ❑ INDIVIDUAL ClCOUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 CESSOR -/Box if INDIAN EPA ID a <br /> of TANK's <br /> ❑ I GASSTATION � 3FARM 12 5OTHEA RESERVATION or ��e �� � � ���� ATTHISSITE Q <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> urL &I/(-- <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> V_ r <br /> MAILINGor STREETADDRESS ✓Bo Indicate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> /�� / /I AA ❑ RPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> r INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> - va, .n e/1-; C19- 9s8/L L!/v <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sof ave <7L <br /> MAILING or STREET ADDRESS ✓Box indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> ❑ PCRATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 1,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. ❑ 11, 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 9 = a <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Sze R <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN�S7US TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> f YES NO 7 —6 — <br /> CHECK# 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($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) • • <br /> DATA PROCESSING COPY <br />