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STATE OF CALIFORNIA— WATER RESOURCES CONTROL"d6ARD � � *''"f <br /> sx�� o, , <br /> FORM `A': ;'�� <br /> UNDERGROUND STORAGE TANK PROGRAM =moo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oa�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 195 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE }..A. <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREcn I to <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION (30 <br /> U 5:N4. <br /> ADDRESS NEAREST CROSS STREET ✓Bmblydicae ❑ P.Wtll&BM 0 SIATEMM,Y <br /> ^jJ 0 CUNPOR411011 0 LDCA4Q20 0 FIIBKL-AGDO <br /> ❑ INDMDUAL ❑ cotfTeNi a <br /> CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CODE <br /> CA <br /> TYPEOFSUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bo%it INDIAN EPA ID # <br /> RESERVATION or N of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ if. ❑ IN.❑ <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 /> 21 1 1 111 C) 1 e <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> vRp 03 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK0 <br /> DE CENSUS TRACT N SUP SOR-DISTRICT CODE BUSINESS PLAN FILED DAATTE LED//FH <br /> 0#3� YES 0 NO o 1�( 0 <br /> 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 /> \V\ J1I FORM A(3-2-88) <br /> J DATA PROCESSING COPY i <br />