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STATE OF CALIFOR i � WATER RESOURCES R E fs ;�:w,'�� <br /> U C S CONT�Oe.:.10ARD � . .. <br /> FORM W: A <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> V7E FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �/" 10 <br /> I COMPLETE THIS FORM FOR EACH FA LITY/SITE <br /> j <br /> LARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE f a <br /> EONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) 00 <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> t nlvh Yos. n <br /> ADDRESS NEAREST <br /> CROSS STREET CORPORATION PRNpP ❑ STATE-AG80 <br /> ❑ LOCAL-AGN ❑ FDR •AGD00 <br /> ❑ INDMDUAL ❑ COUNTY-AGENCY <br /> iCITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> i CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PRTOS60 ✓Box if INDIAN EPA ID a <br /> RESERVATION or <br /> 1 GAS STATION ❑3 FARM ER TRUST LANDS ❑ (iL 1.#T.f.TANK's <br /> ISOTHSITE <br /> i <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(LA ,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> t <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> i NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESK ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> 1 fv',L- 4? <br /> 61�_ - 1III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> I NAME CARE OF ADDRESS INFORMATION <br /> 57ge a4ave <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> j CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. EK 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> I <br /> I APPLICANT'S NAME(PRINTED a SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I EI I LtT l 0101Q <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> N7CIN <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 3613 YES ❑ NO ❑ �� <br /> CHECK N 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY C- <br />