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STATE OF CALIFORNIX WATER RESOURCES CONTROYBOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY eCLOSED SITE I'J� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .1�D W <br /> I.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SIT �1 NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓3"wI,ddI* D PARTNERSHP D STATE'AGENCI <br /> J� D CORPORATION D LOCAL AGENCY D FFDERALAGBICY <br /> ❑ INOMWAL D COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSORif INDIAN EPA ID a X o1 TANK'1 <br /> ❑ 1 GAS STATION ❑ 3 FARM El OTHER RESERVATION <br /> ✓BoxRUSTYATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATIO <br /> SC_¢A.lL_a,--. . n� tv L Jska <br /> MAILING or STREET ADDRESS ✓Box to intlicale D PARTNERSHIP Cl STATE-AGENCY <br /> D CORPORATION Jii-COCAL-AGENCY D FEDERAL-AGENCY <br /> SZo D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> � Q a�9 63� 35`i <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SQ ro-A 0L0 IX <br /> MAILING or STREET ADDRESS ✓Box tainol,rwe D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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. IIT❑ <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 a JURISDICTION R AGENCY R FACILITY ID M 41 of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN OLI.. O APPROVED BY N PHONE A WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COpE CENSUS TRACT Y SUPERVISOR�-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDq 6 <br /> E3 NO 0 <br /> CHECK R 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 /> ORM A(3-2-881 S <br /> `W' `/ DATA PROCESSING COPY Vol, <br />