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STATE OF CALIFORNWATER RESOURCES CONTRONARD <br /> W <br /> FORM `A': °m <br /> UNDERGROUND STORAGE TANK PROGRAM 0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C <br /> COMPLETE THIS FORM FOR EACH FACIL TY/SITE C9�!FORN�P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN NTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rV <br /> CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS - NEAREST CROSS STREET ✓ indicate ElPARTNERSHIP ElSTATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 7 STATE ZIP CO SITE PHONE At,WITH AREA CODE <br /> CA M <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ATION*/Box if INDIAN EPA ID a <br /> [:j1 GAS STATION ❑ 3 FARM El OTHER TRUSTESEVLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA C.�,O,,DF,� <br /> NIGHTS: IAME(LAST.F T) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIR T) PHONE Al WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADD SS INFORMATION <br /> MAILING or STREET ADDRESS �� ✓ to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE P E a,WITH AREA CODE <br /> a -),4 1 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME M // /f 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 a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS lZ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. 50, 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> UE1 I III I I llc+-AILJ�_I , TCT31 <br /> L.,;I I Lol I C) <br /> CURRENT LOCA GENCY FACILITY ID JL APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> C YES NO /O j <br /> CHECK# PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT# 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) <br /> ft DATA PROCESSING COPY J <br />