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N�STAVE OF CALIFORNIA"---' WATER RESOURCES CONTROL 6:1ARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> VTE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ov COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cl <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 1� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓8�indcale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> TION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O I/1 INDNIDUA'l ❑ CWNTY-AGENCY Q� j <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA q 2,Dq 3 —O <br /> TYPE O USINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or >f o1 TANK's <br /> 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#WITH AREA CODE <br /> r so ri 2oG 9,4 3 0 1�- <br /> NIGHTS: NAME(LAST,FIRS fj PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE K WITH AREA CODE <br /> �otJ 2 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /�— <br /> MAILING or STREET ADDRESS �✓ x to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> N CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N ME STATEZIP CODE PHONE It.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓/Balrl io indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LK CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE N,WITH AREA CODE <br /> 01_(-A nAb G_6ZM <br /> IV. LEGAL NOT KATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1f JURISDICTION 1t AGENCY M FACILITY ID M k of TANKS at SITE <br /> aE I I _L L It--doill,9119Z00 © <br /> CURRENT LOCAL AGEY FACILITY ID k APP VED BY N�1 E PHONE N WITH AREA CODE <br /> N <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMlIfEXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT O SUPERVISOR-DI RICT CODE BUSINESS PLAN FILED DAT"LED/ <br /> 3,'S <br /> , YES NO D <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R 6: <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) <br /> �� DATA PROCESSING COPY �� <br />