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STATE OF CALIFORNIA emsese, WATER RESOURCES CONTROL Ba cHD <br /> FORM A% UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE © FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT E] 3 RENEWAL PERMIT CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O Z <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITENA _TbME CARE OF AD RESS INFORMATION <br /> �o w R L <br /> ADDRESSl NEAREST CROSS STRri <br /> EET Li20hPOAATIle 71 ION E PARTNERSHIP <br /> SHIP E S7ATEFEDEAGEND a)Iw <br /> 91 F SI E NiIE COUNIYAGEti VI <br /> CITY NAMEYD 1 STATE ZIP CODE SIT PHONE tl,WITH AREA CODE Lq <br /> N CA /3 / <br /> TYPE OF BUSINESS'. ❑ 3 DISTRIBUTOR 4 Pfl SSOR ✓Box it INDIAN EPA ID If <br /> RESERVATION or N of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ (r�/ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE It WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 3 W �? 3 <br /> NIGHTS' NAME(UST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST FI ST) PHONE It WITH AREA CODE <br /> 3 <br /> II. PROPERTY OWNER INFORMATION ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> N . unTId2T S , <br /> MAILING or STREET ADDRESS ✓5�a 1uu indicate E PARTNERSHIP E STATE-AGENCY <br /> Gd'CORPORATION E LOCALAGENCYE FEDERAL-AGENCY <br /> � , TI-0D VA' �1,� -S1 E INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME /1 STATE ZIP CODE PHONE p,WITH AREA CODE <br /> K 6�v 3(aCo -to 3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate E PARTNERSHIP E STATE-AGENCY <br /> E CORPORATION E LOCAL-AGENCY E FEDERAL-AGENCY <br /> E INDIVIDUAL E COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE d.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. II. ❑ If.❑ <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 N JURISDICTION R AGENCY R FACILITY ID N If of TANKS at SITE <br /> 3 � I nU I1 I C1 lol I (I I oc) <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE <br /> i <br /> (✓ <br /> PERMIT NUMBER PERMIT APPROVAL DATE MIT EXPIRATION DATE <br /> 2 <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O 810 YES NO <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ BY: <br /> 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 ONLY. <br /> 0 M A(3-2-SS) <br /> DATA PROCESSING COPY <br />