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STATE OF CALIFORNII WATER RESOURCES CONTRIPBOARD <br /> FORM `A': 4 <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> a` COMPLETE THIS FORM FOR EACH CILITY/SITE OR P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> pa,d A"I <br /> ADDRESS `_/ NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> / 3 / <br /> S, M�G ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE / SITE PHONE M,WITH AREA CODE <br /> CA (� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIA EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ATION or ❑ Sof TANK'T <br /> �ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIpR/ST) PHONE p WITH AREA CODE DAYS: NAME(LAST OD <br /> IRST) PHONE k WITH AREA CE <br /> ff <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE»WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME , 'a CARE OF ADDRESS INFORMATION <br /> IIg <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /' / SO� ❑ CORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> (/ J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ( STATE ZIP CODE PHONE It,WITH AREA CODE <br /> LA rZ 1 vJ Gt,I.vt e� C� O U <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 C] COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE tf,WITH AREA CODE <br /> L <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. ❑ 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 /> ENUMBER <br /> JURISDICTION N AGENCY 8 FACILITY ID M S of TANKS at SITE <br /> F3MP51- 16) &) _71 <br /> ENCY ACILITY ID K APPROVED BY NAME PHONE N WITH AREA CODE <br /> r,F R F 7 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT M SUPERVISOR-DISTRICT C DE BUSINESS PLAN FILED DATE FILED <br /> YESO ❑ CjPERMIT AMOUNT SURCHARGE AMOU _f_FEE CODE RECEIPT N BY: // <br /> G�✓/�� <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(3-2-88) • . '/) <br /> V <br />