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STATE O i ALIF RiVQWATER RESOURCES CONTR�BOARD s �:T"F� <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ACI TY/SITE, INFORMATION and/or PERMIT APPLICATION - z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERtr`7 ITE F'a <br /> ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> W <br /> FACILITY/SITE NAME r' CARE OF ADDRESS INFORMATION <br /> ) ^ — <br /> ADDRESS NEAREST CROSS STREET ✓Bax 10Wicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,ti r3i M ^,,, ❑ <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> l ' �"""" ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 7 CA q J-3-76 1 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if NDIAN EPA ID a FATTHIS <br /> SI <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME ST,FIRST) PHONE#WITH AREA C-1 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROP/6TY,15WNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> A CARE OF ADDRESS INFORMATION <br /> AMA9,5_64A-D <br /> MAILIN or STRE DDRES ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �/{ j]/�� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> !"" i J ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> -- a o : L- <br /> III. TANK OWNER INFORMATIO ESS — (MUST BE COMPLETED) <br /> NAME ARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. If <br /> 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> F3-1-q A 9 I :z- I Lolvv ® <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Y <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> C? YES ElNO ❑ 6 o- <br /> _[CHECK# PERMIT AMOUNT SURCHARGE AMOUN FEE CODE RECEIPT# 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 /> ORM A(3-2-88) <br /> ✓lq\pl, 0 DATA PROCESSING COPY (� <br />