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STATE 4F CALiFOR WATER RE is�a` €~Fh <br /> SOURCES CONTSBOARD ��~ E <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b. ` <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ! <br /> CgAIFpp NSP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7101 <br /> ENTLY CLOSED SITE <br /> ONE ITEM V2 INTERIM PERMIT 1:14 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> F ILITY! ITE NAME ` __ CARE OF AVDRESS dNFORMATION <br /> ADDRESS 'r(JC A ST CROSS ST ET ✓ o mkdle ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,� / C 11 _0CAL-A3ENGY <br /> -"`_ - U PDUAL GN ❑ COUNTY RG 4CY ❑ FEDERAL-AGENCY N <br /> CITY NA STATE ZIP CO 7 ITE P NE#,WITH AREA CODE <br /> C,�.' CA J �� �`t <br /> TYPE OF BUSINESS: 2 DISTH18UTOR 4 PROCESSOR ✓Box it INDIAN EPA ID <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or p of TAN <br /> TRUST LANDS ❑ SITE AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) 4� PH NE N WITH AREA CODE DAYS: NAM (LAST,FIRST) <br /> PHO #WITH AREA CODE <br /> v� <br /> NIGHTS: NAME LAST,FI T) PH07 4 ITH AREA CODE NIGHTS E(LAST,FIRST) PH7134#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NWf <br /> CARE OF DAESSlNFORMATION <br /> M G r STR T AODR V to indicate ❑ PARTNERSHIP QSTATE-AGENCY <br /> / RPORATION E] LOCAL-AGENCY ❑ FEDFRAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE //�E�..__,, ZIP CODE PHONE", ITH AREA CODE } <br /> ( � 1 rj <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADC1RElS5RMATION <br /> ZM -- ////��/// <br /> MAdLiNGSTR ADDRESS ✓BKlo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE Z CODE PHONE ,WITH AREA CODE <br /> CA <br /> y <br /> IV. LEGAL OTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 1). III.❑ <br /> THIS FORM HAS BEEN COMPLETED CINDER 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# AG€NCY# FACILITY ID# #of TANKS at SITE <br /> El I I 1 -1 1 ol 0 z �, <br /> CURRENT LOCAL AGENCY F CILITY ID# APPR VE BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER P IT PPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED <br /> D E FI ED <br /> YES NO <br /> CHEC # PERMIT AMOUNT SURCH RGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION e7. <br /> ORM A{3-2-68} <br /> DATA PROCESSING COPY <br />