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STATE OF CALIFORNIA WATER RESOURCES CONTROL,...,ARD "' <br /> 4 <br /> r. <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FAC ITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT El S CHANGE OF INFORMATION ❑ 7 PERMAN NNILYCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATIONS ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET -/Bat f6C7Y ❑ PMT1EfIS V ❑ STATE AGENCY <br /> ❑ CMIXIATION ❑ LOCAL-AGDO ❑ IMMAGDO <br /> Q ❑ Numm Cl COU m.AGENCY <br /> CITY NAME STATE ZIP CODESITE PHONE 9.WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCE ✓Box B INDIAN EPA IDS If of TANK'S <br /> ❑ I GAS STATION ❑3 FARM HER TRUSTVATION LANDS« ❑ AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> -3JL[ Z,/" 21,2n - y 77-6 <br /> NIGHTS. NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGH S: NAME(LAST.FIRST) PHONE M WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION S ADDRESS —(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 9.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION S ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Gr Ilei oL�r o <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY <br /> / y( ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK-0NE(1)SOX INDICATING WHICH AMOYt ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND SLING: L ❑ U. ❑ NL❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION S AGENCY# FACILITY ID S 0 of TANKS b SITE <br /> m <br /> o l /_k M v o c� <br /> F-1 <br /> CURRENT LOCAL AGENCY FACILITY 10 M APPROVED BY NAME PHONE`a WITH AREA CODE <br /> VO L� 8U <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT I► SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT[FILED <br /> a_(D YES ❑ NO S'1T0 <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• 1Y: <br /> Cf3 <br /> THIS FORM MUST SE ACCOMPANIED SY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.n <br /> FORMA(3-2 E78) �` <br />