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STATE OF CALIFORNIif WATER RESOURCES CONTRO OARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM Z® a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I <br /> A'4lIFOR��A <br /> (2- <br /> Ly COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY <br /> E] PERMIT PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM Illr���l�"`(INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G bo <br /> IJ <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE <br /> NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓CORPORATIOemareN <br /> D PARTNERSHIP D FEDERA AGENCY n r D CAAPDUALIory ❑ LDGLAAGEN Cl FEDERAL <br /> (/)}� ❑ INDIVIDUAL ❑ CAUNIYAGENIX <br /> CITY NAME <br /> STATE ZIP CO���� SITE PONE N.WITH AREACODE / <br /> TYPE OF BUSINESS: ❑2 DIST OR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N If of TANKY <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM HER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> DAYS NAMEAUAST,FIRST) <br /> {� / <br /> T <br /> CAU <br /> NIGHTS: NAME!,LAST,FI T) <br /> PHONE N WITH AREA CODE NIGHTS: NAM I(LAST,F ST PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME n CARE OF ADDRESS INFORMATION <br /> �tf✓Y"�/ ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION D LOCAL AGENCY D FEDERAL-AGENCY <br /> S Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PH E p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> P (vim <br /> MAILING or STREET ADDRESS %/Box to indicate 11 PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY# FACILITY ID# #of TANKS at SITE <br /> PRtj <br /> FACILITY ID# <br /> LAPPROVED ME PHONE N WITH AREA CODE <br /> � <br /> PERMIT APPROVAL DATEPERMIT EXPIRATION DATE <br /> // —/O8U5 TRACT N SUPERVISOR-DIBU7R;ECEIPT <br /> DATE /LEDovrl J^j js�jJ(/-} NO ❑ // �AMIT AMOUNT SURCHARGE AMDEIf <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1�MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> v FORM A(3-2-88) <br /> DATA PROCESSING COPY 46 <br />