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STATE OF CALIFORNIdt: WATER RESOURCES CONTROLti06ARD <br /> e �s. <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> cl COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT � CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 Z <br /> IC <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/ TE AME CARE OFADDRESS INFORMATION <br /> Q- � N <br /> ADDRESS ///111N NEAREST CRO SSTR �✓ miMrcaie ❑ PARTNERSHIP ❑ STATE AGENCY a <br /> i A �I JkCOAPGRATION Cl LOGAIAGENCY ❑ FEGERALAGENCY O <br /> (Q G ❑ INDIVIDUAL ❑ COUYY AGENCY A <br /> CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> � �� p CA S' <br /> TYPE OF BUSINESS: ®`2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID # /yo y� #of TANK'N [/9 <br /> ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHEfl TRUSTVLANDS or ❑A , \ AT THIS SITEATION /( <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> FAYSTSNA E(LASTFIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> Bz�9NAME(LA IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -S0l.rr_lAe_ <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME I <br /> ,[ ,, CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to wd1cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION 81 ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ccg S( <br /> MAILING or STREET ADDRESS ✓Ban to intlicale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ,� it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS at SITE <br /> E 10cl 03 oa <br /> CURRE T LO AL AGENCY FACILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> ass <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE <br /> LY 3 140$y FI�LE,D{ <br /> QG 1,/ Fes/ YES ;Z— <br /> CHECK <br /> ZLCHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) mss. <br /> 1a� DATA PROCESSING COPY <br />