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STATE OF CALIFORN v<I WATER RESOURCESCONTRDCBOARD '` "E <br /> FORM `A': (%- `", <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH F ITY/SITE `'<,.eeH`• <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P CLOSED SITE f"a <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 /> ADDRESS o AC <br /> '/ NEAREST CROSS STREET ✓RvaPm k ElPAtITNERSMP 11 $TATE-AGENCY <br /> 7 //l /� ElCOFIRDIATION El LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ iNDmDIw ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N. ITH AREA CODE <br /> CA �" <br /> TYPE OF BUSINESS: 0 2 PfRIBUTOR ❑ a PROCESSOR I ✓Box it INDIAN EPA ID N <br /> RESE❑ 1 GAS STATION 3 FARM EJ5 OTHER TRUSTYLANDS 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 li <br /> -7�449 ,ire, ZAO). U/L (.,— <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILNNG or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> OCORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 611e- ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE_ PHONE N,WITH AREA CODE <br /> /! <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,ftcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ClCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ If. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID N N of TANKS at SITE <br /> ® 010 / / V 101 61d <br /> CURRENT LOCAL AGENCY F C APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUSTTR/ACTN SUPERVISOR-DISTRICT�yODE BUSINESS PLAN FILED DATEFJLED/� qONLY <br /> L3 Z I Z(/ YES NO � Q CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATI <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY J <br /> � <br />