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STATE OF CALIFORNiP-s- WATER RESOURCES CONTROrTIOARD ' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . <br /> COMPLETE THIS FORM FOR EACH FAC /SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S cr <br /> r <br /> Im <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS�STREET / �% WAPOPTION 0 LOCAL-AGEITAT <br /> NCY 0 SEALAGO <br /> E <br /> /(o <br /> _S _ Nomodu 0 COUNIN AGENG( <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> i�Gi., ecu CA y.s-336 <br /> TYPE OF SINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR RESERVATION f INDIAN <br /> or EPA 10 N <br /> M of TANK's <br /> L 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> i�rce <br /> NIGHTS: NAME(LAST, RST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> //D Co,) SG/i»OSA <br /> MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> �� t� 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �1 f- ✓ Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> C-4 1 9p 3S <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4.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: 1. it. ❑ Ill.❑ <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 k JURISDICTION X AGENCY k FACILITY ID If If of TANKS at SITE <br /> 3 y a y i C U c'- c <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED PATE FILED <br /> a ill 1) 30�0 3 cP6, I YES ❑ NO NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT 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 /> FORMA(3-\) �1 <br /> �� DATA PROCESSING COPY � <br />