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STATE OF CALIFORNO WATER RESOURCES CONTIPBOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM =°° m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> M 10 <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE `+�„o �P <br /> ARK ONLY ❑ ( NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I”& <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -I <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) F+ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,06771fiA/ 7E'UC-77 <br /> ADDRESS <br /> �_ NEAREST CROSS STREET ✓Box toW-P 0 PARTNERSHIP ❑ BipTE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCf ❑ FEDERALAGENCY <br /> CITY NAME p Cl INDIVIDUAL 0 COUNNAGENCY <br /> T Q STATE ZIP CODE I SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p RIBUTOR ❑ 4 PROCESSOR ✓80,if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM ❑5 OTHER TRUST LANDS RESERVATION0r ❑ #of T <br /> AT THIS SI SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME32 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP <br /> 1:1 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCALAGENCY0 FEDERALAGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> STATE ZIP CODE PHONE q,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.,STREET ADDRESS ✓Rox to intlicate 0 PARTNERSHIP <br /> D STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> 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: 1. II. 111. <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# <br /> #of TANKS at SITE <br /> qa3F61 <br /> CURRENT LOCAL AGENCY FACILITY #�� APPROVED BY NAME <br /> PHONE#WITH AREA CODE <br /> EF <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LO ATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED <br /> NFILED NO DATE FILEDYES () <br /> CNE K# PCEB)3IT pMo00NT 3 / <br /> SURCHARGE AMOUNT RECEIPT# BY: <br /> FEE CODE ` <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, / <br /> FORMA(3-2-581 V <br /> weDATA PROCESSING COPY a <br />