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Y <br /> STATE OF CALIFORN <br /> WATER RESOURCES CONTRO�SOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �no <br /> m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 15E?RIM <br /> MIT ❑ 3 RENEWAL PERMIT C� , CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CIE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> n _ OPA <br /> ADDRESS NEAREST CROSS STREET ✓Bo�gw0.ndicale ❑ PARTNERSHIP ElSTATE-AGENCY <br /> Gi" FPORATION Cl LOCAL-AGENCY ElFEDERAL-AGENCY ' 4 <br /> 3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY 4bb <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE cz <br /> CA Q�33(o _I3 <br /> TYPE OF BUSINESS: p DISTRIBUTOR F—]4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION ort , #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM R TRUST LANDS ❑ Ivd�j AT THIS SITE r <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR T) PHONE#WITH AREA CODE NIGHT : NAME(LAST,FIRST) PH NE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CcbnSibeM*_jTele <br /> MAILING or STREET ADDRESS ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 00"I <br /> 1 ORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> V ( V . ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I11. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> lra� C <br /> MAILING or STREET ADDRESS ✓Bax irate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CJS- <br /> 533 <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. ❑ it. ❑ 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 /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> U-31lolol- I +1 �- s� © vd I <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> i-, 3 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT Colt/ BUSINESS PLAN FILED DATE FILED <br /> �— YES NO PERMIT AMOUNT SURCHARGE 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 /> ORM A(3-2-88) 10 <br /> DATA PROCESSING COPY 0 <br />