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STATE OF CALIFORNIA!' WATER RESOURCES CONTROYBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Ke-0 AOOI& ✓! <br /> ADDRESS NEAREST CROSS STREET 10 Klogla 0 PARTNERSHIP 0 STATE AGEN'6Y <br /> CCHPDBATION 13LOLAGENC ❑ FEGEIUAGENCY <br /> NRI ClI COUNTY AGENCY L CY <br /> CITY NAME STATE ZIP CODE ITEP ONE X,WITH AREA CODE <br /> eJ.1 CA G1 S3Coto C) I- - <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR --/Box if INDIAN EPA ID N <br /> #of TANK'X <br /> RESE <br /> 1 GASSTATION 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME Dome- CARE OF ADDRESS INFORMATION <br /> S - <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMELY - CARE OF ADDRESS INFORMATION <br /> \\�aMe <br /> S Si�PJ <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CIN NAME STATE ZIP CODE PHONE X,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. 11. ❑ Ill. ❑ <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 /> CURRENT CAL AGENCx-FAQILI IDN APPROVED BY NAME PHONE X WITH AREA COD <br /> PERMIT NUMBER �•(\Q_`) PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK <br /> DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3.a3 3a YES ❑ NO ❑ &— -� <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX 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(3-2-88) - <br /> -saw DATA PROCESSING COPY ...F <br />