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STATE OF CALIFORNIP WATER RESOURCES CONTROSOARD <br /> QPM ..S9 <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM >m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�IFOR to'P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-�► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE (, <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> (IDUiC <br /> ADD SS NEAREST CROSS STREET ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> !^ '' t_ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ID INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME r STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA � � 0 <br /> Zl <br /> BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> AS STATION E]3 FARM ❑ 5 OTHER <br /> RESERVATION <br /> RUST LANDS or ❑ AT THIS SITE <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,FIRS-M PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> Platted 0 3&'(— 3 501 <br /> II. PROPERTY OWhER INF66RMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rjzu;5( _7:S' m f nG, <br /> MAILIN or STREET ADDRESS n ' ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CL4 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME F STATE ZIP CODE PHONE#,WITH AREA CODE <br /> � d'' �i5 — ate <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sammi S <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: 1. ❑ II. 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 /> UDI I I I I D o I alo- I fiz] L6 IoF�2 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVEDVQN E PHONE#WITH AREA CODE <br /> / .� <br /> PERMIT NUM R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1/ lW l <br /> LOCATION CODE CENSUS TRACTS/#Y� SUP RVIS JR-DISIRT CODE BUSINESS PLAN FILED DATE FILED <br /> 3, (Cd YES E] NO E] /� /� kr <br /> CHECK# 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />