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I <br /> STATE OF CALIFORNLa.c WATER RESOURCES CONTRe...YBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o< 1 o <br /> e COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION NENTM D SITE F'J' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V � <br /> CA <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> t0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ,- <br /> ADDRESS NEAREST CROSS STREET ✓er�i rgime ❑ PAATNEASHIP ❑ SLATE-AGENCY <br /> T tS OPATION ❑ LOCA-AGENCY ❑ FEDEMLAGENCY <br /> r ❑ INDNIWAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p.W <br /> CA a 2 <br /> TYPE OF BUSIN SS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz it INDIAN EPA ID » X of TANK'e <br /> ❑ 1 GASSTATION [:] 3 FARM F-15OTHER TRUSTYANDS or ❑ 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 N WITH AREA CODE <br /> a0 9 � -5951 <br /> NIGHTS: NAME LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (ao9 -� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> n <br /> MAILING or STREET ADDRESS / ✓ io intlicate ❑ PARTNERSHIP EISTATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATES ZIP CODE D PHLTH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) Y <br /> NAME CARE OF ADDRESS INFORMATION <br /> S Q <br /> MAILING or STREETADORESS ✓Box 1°intlicele 11 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: L ❑ ll.X 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 M JURISDICTION N AGENCY N FACILITY ID k R of TANKS at SITE <br /> ® � 4D / 9 d <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE a WITH AREA CODE <br /> a <br /> PERMIT NUMBER PERMIT APPROVAL D TE PERMIT E%PI ATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPER OR-DISTRICT CODE BUSINESS LAN FILED DATE FILED <br /> 0 'l � A YES � NO � 1XIANT1 <br /> CHECKVvk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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-II3) <br /> DATA PROCESSING COPY <br />