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OVSTATE OF CALIFOR WATER RESOURCES CONOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = M1a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f ! <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY 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�TE NAME CARE OF ApDRESS INFORMATION <br /> ADDRESS NN�,B,F3E T CROSS STREET ✓Boz to indicate ARTNERSHIP E] STATE-AGENCY <br /> S G El CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �' ❑ INDIVIDUAL ❑ COUNTY-AGENCY 00 <br /> + STATE ZIP ODE ITE PHO E#,WITH AREA CODE <br /> CITY�+AM,E, �S� e <br /> L-U D) CA l"'l1 �/(,l/tJ Zo�'1 361-2,72A7_ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR V4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM L5 OTHER TRUSTRESERv ANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY_ S: NAME( T,FIRST) PHON #WITH AREA CODE DAYS: N E(LAST,FIRST) PHONE Y#,WITH AREA CODE <br /> 3 <br /> NIGHTS: NAME(LAS ST) / PHONE I WIT�FjEA CODE NIGHTS:/NAME(LAST,FIRST) PHON WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF PIDDRESS INFORMATION <br /> �4 d R NIA <br /> MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ,WITH AREA CODE _ <br /> �G D( C `1 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF AD SS INFORMATION <br /> S p, <br /> MAILING 6r STREET ADDRESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> 1 % ` ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. 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 /> ] I ] I 6 � 3 3 1 odd 1I] <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ikc <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 '2-- <br /> 6YES ❑ NO -KW 0 <br /> l <br /> CHECK# PERMIT AMOUNT SURCHARGE AfAOUNT 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 I <br /> FORM A(3-2-88) <br /> 0 DATA PROCESSING COPY <br />