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STATE OF CALIFORNP WATER RESOURCES CONTRBOARD a <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMSITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE JTQ 7" <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I o <br /> FACILITY/SITE NAME CARE OF gDORESS INFORMATION <br /> ADDRESS N <br /> NEAREST CROSS STREET ✓0ov to irAirate ❑ PARTNERSHIP El STATE'AGENCY (,D <br /> / a" O ❑ C POAPON ❑ LOCAL AGENCY ❑ FEEMLAGENL'Y W <br /> OIVIOUAL ❑ COUNIP-AGENCY <br /> CIN NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> Seo c f� vU CA S a o Cao S <br /> TYPE OF BUSINESS: I—I Z DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> AS STATION 1❑13 FARM HER RESERVATION or �/�nA AT THISIf of SITE Q <br /> TRUST LANDS ❑ I(JV `""« AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Lao <br /> NIGHTS 03 <br /> NIGHTS. NAME(LAST FIRST) P ONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE if WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> -j- ,eme,S W, Fga -/'e r <br /> MAILING or STREET ADDRESS A/Box to intlicate El PARTNERSHIP 11STATE-AGENCY <br /> A ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> sayhp- <br /> n <br /> MAILING or STREET ADDRESS 1/80.to intlicate ❑ PARTNERSHIP ❑STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.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 If AGENCY# FACILITY ID If If of TANKS at SITE <br /> = = 10101l 17 ,/ OO © d <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN NG ❑N❑FILED DATE FILED�� <br /> © 1 [Q� <br /> CHECK# PERMIT AMOUNT SURCHARGEAMO NT FEE CODE RECEIPT If B <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 ONL <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />