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STATE OF CALIFORNIA..- WATER RESOURCES CONTROL4ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT ©CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE co <br /> 00 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) .p <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> S-, <br /> ADDRES5 NEAREST CROSS STREET 41 Em ✓ m9icale �EOIPAKNFFPSHIP ❑ STATE-AGENCYCORPORATIONNCY ❑ FEDEFIAL-AGENCY❑ IN�IYIDGAL ENGY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA q SZ-o1(2-1 4 -S(cc <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if IiEPA0 # #of TANK's <br /> ❑ I GASSTATION ❑ 3 FARM ER TRUSTTMATION LANDS or 1:1A7 THIS SITE <br /> OTH <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS, NAME(LAST.FIRST) PHO E#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME( ST,FIRST) )DINE#WITH AREA CODE NIGHTS: �E(LAST.FIRST) P NE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO & ADDRESS — (MUST BE COMPLETED) <br /> NAM / CARE OF ADDRESS INFORMATION <br /> I!V CL <br /> MAILING or STREET ADDRESS ✓Bax to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> S fllj <br /> MAILING or STREET ADDRESS �✓,�c indicate F-1PARTNERSHIP ElSTATE-AGENCY <br /> FV 130 ISGORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> _5 C <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. ❑ VII. <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(PRINTF➢&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> AGENCY FAC IID# APPIF119WED BY NAME ONE ITN AREA CODE <br /> C /&-E- <br /> rPER NUMBERPERMIT APPROVAL DATE RMIT EXPIRA N DATE <br /> ION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3. yj�1 YES NO <br /> CHECI& PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST HE 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(3-2-88) <br /> ftwy DATA PROCESSING COPY <br />