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STATE OF CALIFORNIF WATER RESOURCES CONTABOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE —4 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILI TE NAME CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓ POMTle ElPARTNERSHIP11 STATE AGENCY <br /> COPI El FEDERAL AGENCY <br /> C INDIVIDUAL C WUNiRAGENCY <br /> CITY STATE CODE SITE PHONE 4.WITH AREA CODE <br /> moo„/ CA 5 <br /> TYPE OF BUSINESS: F] 2 DISTRIBUTOR El PROCESSOR ✓Bax4INDIAN EPA ID H Xo1 TANK's <br /> E] 1 GAS STATION ARM E] 5 OTHER TRUST LANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME. CARE OF ADDRESS INFORMATION <br /> �. M <br /> MAILING or STREET ADDRESS . .le intlicale Cl PARTNERSHIP C STATEAGENCY <br /> L CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> G� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> /v <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S' aApoK <br /> MAILING or STREET ADDRESSor ✓Box la Indic.e ❑ PARTNERSHIP Cl STATE AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. 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 a JURISDICTION k AGENCY n FACILITY ID If K of TANKS at SITE <br /> of <br /> CURRENT LOCAL LFACID <br /> ^ D APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA N CODE SUPERVISOR--DISTRICT CODE BUSINESS PLAN FILED DTE FILED <br /> YES E] NO ECHECKM SURCHARGE AMOUNT FEE CODE RECEIPT F 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 /> FORM A(3-2-88) • V <br /> DATA PROCESSING COPY <br />