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STATE OF CALIF014IA WATER RESOURCES COOL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �e <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Grp <br /> .. ADDRESS NEAREPT CP03S STREET .✓ iqN 0 PARTNERSHIP 0 STAT. EN GY N <br /> � waaclal,& ❑ LOCAL-AGENCY ❑ FEDEAALAGENCY 00 <br /> CITY NAME <br /> ❑ INDIVIDUAL FICOUNTr-AGENCY r <br /> STATE ZIP CODE SITE PHONE a.WITH AREA CODE <br /> Y CA <br /> TYPEOFBUSINESS: 2 DISTRIBUTOR 4PROC R I/Box if INDIAN EPA ID <br /> 1 GAS STATION 3 FARM THER RESERVATION or ❑ #of TANK's / <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(L)NST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME a <br /> CARE-OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS �y 'l ✓ ointlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> /Lt�iC/V CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> U ,2C) <br /> MAILING or STREET ADDRESS antlicate FI PARTNERSHIP 11 STATE-AGENCY <br /> /,:;L- 11 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> colq- <br /> 3�a- <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. 0 II. El 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 If AGENCY# FACT If of TANKS at SITE <br /> C <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED NAME HONE#WITH AREA CODE <br /> Irl+ <br /> PERMIT NUMBER PRM IT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT ON CODE CEN TRACT�� SUPERVISOR-U STRICT$ODE BUSINESSPLAN❑FILED NO ❑ DATE FIL2 <br /> CHECK# PERMIT AMOUNT SURCHARGE AA/MOUNT FEE CODE gECEIPTN BY: <br /> assasal <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 13-2-BUT <br /> \�J 4b DATA PROCESSING COPY • <br />