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STATE OF CALIFORNIA WATER RESOURCESCONTROI*ARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> l/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT s CHANGE OF INFORMATION ❑�71�ERMAN <br /> EN CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> 41 <br /> FACILITY/SITE NAME . rr ^/ CARE OF ADDRESS INFORMATION <br /> �Iv n <br /> ADDRESS � 1 NEAREST CROSS STREET ✓9mbindoa ❑ FAAINEMP ❑ STATE AGENC! <br /> S ❑ coRpoRATa+ Cl LocALAGm ❑ FEDERALAGDO <br /> L4 qI f ZI LN ❑ INoroDUAL ❑ COUNTY AGENC/ <br /> CITY NAME STATE ZIP CO � / SITE PHONE N,WITH AREA CODE <br /> CA I <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR I/Box if INDIAN EPA 10 # p/, 17" N of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or F-1AT 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 k WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE W WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(/)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ElIf. [:1III.El <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 IN JURISDICTION K AGENCY R FACILITY ID Al R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FAFILITY IDS^ / APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER '"(PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONCODE CENSUSTRACTO SUPERVISOR-DISTRI T CODE BUSINESS PUN FILED DATE FILED <br /> 2 3g3 Z YES ❑ NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. b <br /> \FORMA(3-2-88) / \ <br /> DATA PROCESSING COPY ✓'✓T <br />