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STATE OF CALIFORN �. <br /> WATER RESOURCES CONTF��BOARD <br /> FORM `A': �•` �a <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'C <br /> MARK ONLY f NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM p INTERIM PERMIT ❑ q AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE d <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILI /SITE NAME <br /> Ser vice <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS �y/y�� NEAREST CRO STREET ✓SOK IP irdiral, ❑ PARTNERSHIP ❑ STATEAGENCr <br /> 75 r / /) 1 0 ❑ CO0��iitSAP RONJ ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> L�IIQ♦OIVIDUA. ❑ COUNTY-AGENCY <br /> CITY NAME y STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> TYPE OF BUSINESS V r+A p� a a •••y <br /> 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> 1 GAS STATION 3FARM 50THER <br /> RESERVATION or ❑ #of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> batcl <br /> �b a -870 <br /> NIGHTS: NAME(LAST,FIRST( FFHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> S tee, <br /> If. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> 3an� ^ � L CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS (� ✓Box to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY❑ INDIVIDUAL ❑ COUNTYAGENCYCITU NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME a n e q.,::) l^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP F1 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ElCOUNTY-AGENCYCIN NAME STATE ZIP CODE PHONE k,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION R AGENCY# FACILITY ID M If of TANKS at SITE <br /> an [� d D / l� V 7 10101 01Y] <br /> CURRENT LOCf1L A¢ENyCIY/�FACILITY ID If APPROV YIN E PHONE M WITH AREA CODE <br /> xp /iI D <br /> PERMIT NUMBERPERMIT APPROVAL TE ^ PERMIT E%PIRA ION DAT Q c� <br /> LOCATION CODE CENSUS TRACT# SUPE VISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> p( 1 (� O .5 YES NO <br /> �(L <br /> CHIC M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> 11LV1 I 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 /> FORM A(3-2-68) <br /> DATA PROCESSING COPY <br />