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STATE OF CALIFORNIA WATER RESOURCES CONTRO ARD <br /> P T <br /> /'SE•••EUPFMA..N�` <br /> WP.' •;sa <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> fto <br /> SITE E FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C krF0 pN`P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> IF <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A.� N <br /> ADDRESS r NEA EST CROSS STREET �oatoindicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION ❑ COUNTY-AGENCY F ERA-AGEN <br /> l��p ..� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA4/I`^ � STATE ZIPDE SITE PHONE#,WITH AREA CODE W <br /> CA1 !!Ec_2,6:3 _f!9SO <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR �� 4 PROCESSOR ✓Box it INDIAN EPA IID # <br /> RESER❑ ❑ (y_J TRUST LANDS ATION Or ❑ !� #of HIS SITE I GAS STATION 3 FARM OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ��HONE WITH�ARE �E DAY N� (LAST,FIRST) PHONE# ITH AREA CODE <br /> IGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIG NAME(LAST,FIRST) PHONE# ITH AREA CODE <br /> -5/A 3 A s A <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDDDRESS INFORMATION <br /> IV <br /> MAILING or b4 <br /> STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> fO CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> `CITY NAM STATE/ ZIP CODE PHONE#,YVITH AREA CODE <br /> f S <br />'{ Ill., TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF A?DQESS INFORMATION <br /> SiA <br /> MAILING or EET ADDRESS )Vox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br />:A- CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I-A ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE' ZIP JE PHON�, ITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS S(( <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 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&SIGNATURE) DATE <br /> j LOCAL AGENCY USE ONLY <br /> i <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® lolo5lolobJ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT(# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> 4 t V YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> as: <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) t+' <br /> • DATA PROCESSING COPY 40 <br />