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STATE OF CALIFOR& WATER RESOURCES CONT BOARD a <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONo <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE051TE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE v 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CO <br /> to <br /> FACILUITYY/SITE NAME CARE OF ADDRESS INFORMATION <br /> -1l *,i TU e `u c i C K-L- <br /> ADDRESS � (( NEAREST CROSS STREET ✓MrIn Wii ❑ PAATNEF&P ❑ STATE AGENCY <br /> n U✓� S ) 11INDIVIDUALDN 13 CDDNTV AG FEDEAALA ENCY <br /> CITY NAM STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CA lC+�� lbs <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID q <br /> RESERVATION or !l of TANKY <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(IAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE At WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1-A—Q —,..I-> <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 N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> cin -I F IR Linc, <br /> MAILING or REETADDRESS�. */Box to indicate Cl PARTNERSHIP ❑ STATEAGENCY <br /> EICORPORATION 11LOCAL-AGENCY ClFEDERAL <br /> �O ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME (�C / SiDECODE PHONE A.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. ❑ it. ❑ 111. <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 R JURISDICTION k AGENCY R FACILITY ID it M of TANKS at SITE <br /> CURRENT LOCAL Ili FACIL TY 10 N APPROVED BV NAME PHONE k WITH AREA CODE <br /> cE\ --v -1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE FPERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT It� SUPERVISOR-DISTRICT CODE SINES;PLAN FILED NO ❑ DATE FILED r�� <br /> CHECK k PERMIT AMOUNT SURCHARGE`AMOUNT FEE CODE RECEIPT V BY: <br /> T IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> M A(3-2-88) <br /> 0 <br /> DATA PROCESSING COPY • <br />