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STATE OF CALIFORNIV WATER RESOURCES CONTR ARD <br /> O <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> r �p <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' <br /> 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "`IFOR"�" <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS!2 ED SITE } <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 01 <br /> FCG <br /> 1. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> ,� Q1 <br /> FACILITY/SITE NAME a)N 7 rlpJ L-v(J ( CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ !o indicate ClPARTNERSHIP ❑ STATE-AGENCY CORPORATION 1:1 LOCAL-AGENCY ElFEDERAL-AGENCYLvb H I OCT- ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CAI 2.0 q 143 -p <br /> jFAS <br /> USINESS: ❑2 DISTRIBUTOR ❑ 4 CESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 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#WITH AREA CODE DAYS: <br /> i NAME(LAST,FIRST) PHONE#WITH/AR�EAA CODE <br /> q L1 --0� 1 l Ot. ,5 i L!_ q I (C' �0 3 I- l0`1 j <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> CzKe" How-v5, I GIS I ' ( 11� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> IL- 'FILLL_ Hoi.Lis <br /> MAILING or STREET ADD ESS SV me 5(00 ✓,� moo indicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> Q 117 CORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> IJ v I 11INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY E STAT ZIP CODE P ONE#WITH AREA CODE <br /> C ) 0 0 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L <br /> MAILING or STREET ADDRESS ✓ ox to indicate El PARTNERSHIP ElSTATE-AGENCYD �j� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> T 1' T INDIVIDUAL ❑ COUNTY-AGENCY <br /> _jei*.q <br /> CITY E �r STAT ZIP CODE PHONE#,WITH AREA CODE <br /> t— <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. if. ❑ 111.❑ <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 /> EPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I D L <br /> AGENCY FACT ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDa3O� YES NOPERMIT AMOUNT SURCHARGE AMOUNT _j__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 ON <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />