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STATE OF CALIFORI WATER RESOURCES CONTR AR v�oF- <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM y o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G 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 <br /> 9� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S &C.k SAC) ry <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> 1 ..J <br /> ❑ CORPORATION ElElLOCAL-AGENCY FEDERAL-AGENCY �y <br /> 3 u �u ;D,49 r s h/ n ElINDIVIDUAL ❑ COUNTY-AGENCY Ci) <br /> CITY NAME C, >i V Y v <br /> STATE C jrR0 SIly TE POHONE N,WWITNAREA CODE W' <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #RESER �`j 7p�` (!� <br /> ❑ ❑ <br /> TRU, <br /> TVLANDS ATION or ❑ C� AT THIS SITE <br /> i GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> 14 <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ctrrt4 14a <br /> NIGHTS: NAME(v.FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME C CARE OF ADDRESS INFORMATION <br /> 1 L011 <br /> MAILING or STREET ADDRESS /y ✓ o indicate 1:1 PARTNERSHIP E-1STATE-AGENCY <br /> lJ / I y PORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> (� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N✓ � �� �© � STA ZIP CODE 147 � P�NE#,WITH AREA <br /> III. TANK OW INFOR ATION &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#,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: I. 11. 111. ❑ <br /> I <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 /> 1 <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> A10 b i�03 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 0011767.5 C®102119r /.21 l ,?F <br /> LOCATION/CODE CENSUS TRACT SUPER ISOR-DISTRI T CODE BUSINESS PLAN FILED DATE FILED <br /> 0 / i �0 YES ❑ NO ❑ I(p <br /> HECK# PERMIT AMOUNT SURCHARGE AMOUNT T��ODE RECEIPT# Y: <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 /> FORMA(3-2-88) C <br /> DATA PROCESSING COPY <br />