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u'i <br /> STATE OF CAL IFORA WATER RESOURCES CONT�L BOARD u � F' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �41,FO0.N�H <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED <br /> MARK ONLY SITE <br /> F-] E] I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE U <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NP/AE) vc( ' CARE OF ADDRESS INFORMATION <br /> ADDRESS 111 „I"`••"//J"`---"' NEAREST GROSS STREET ✓BOKb lydvak ❑ PAIRNEISHIP ❑ STATEFEDERAL <br /> EDERA AGENCY <br /> �^ r ❑ CGAPORAiION ❑ lOG4LAGENCV END <br /> ❑ FEGEAALAGENCI <br /> ❑ INOIVIGUAL ❑ COUNTY AGENCY <br /> STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CITY NAME S /C/✓, <br /> CA <br /> TYPE OF BUSINESS, ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID q X of TANK'e <br /> 5 OTHER RESERVATION ar ❑ AT THIS SITE <br /> F__][NIGHTS: <br /> 1 GASSTATION ❑3 FARM ❑ TRUST LANDS <br /> ERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> '. NAME(LAST,FIRST) <br /> PHONE#WITH AREA COOL DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NAME(LAST.FIRST) <br /> PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I1. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> ;NAMEAILING or STREET ADDRESS ✓Box mod,,,ate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> Cl INDIVIDUAL 0 COUNTYAGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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 /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> L NI JURISDICTION <br /> AGE FACILITY ID# #of TANKS at SITE <br /> COU <br /> 79 1 1 -, oac] <br /> CURRENT LOCAL AGENCY FACILITY ID# O (� f i <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE\J PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTjiICT CODE BUSINESS!S NFILED NO ❑ DATE F LED <br /> �r//jMO T dA"LL��11 RECEIPT# BY: <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />