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STATE OF CALIFORNIP WATER RESOURCES CONTROIL9OARD <br /> ;� �m <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> O'r IIFOP�'P <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMA TLV CLOSED SITE {"a <br /> MARK ONLY NEW PERMIT -I <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) C) <br /> I� CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME �6I -7 )` F__ ( /',I ' <br /> /�/ l..ir{(�1/V( NEAREST CROSS STREET ✓Box Module ❑ PARTNERSHIP 0 STATE AGENCY <br /> ADDRESS �I 0 gORPORAL 0 LOCAL EN ❑ FEDERAL <br /> ��/�lot ❑ INDNIOUAL ❑ COUNTY <br /> STATE ZIP CODE SITE <br /> SITE PHONE tt.WITH AREA CODE <br /> CITU NAME CA <br /> -1 Box it INDIAN EPA ID N #of TANK'N <br /> TYPE OF BUSHES$: F-12 DISTRIBUTOR ❑ 4 PROCESSOR RESERVATION or AT THIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE p WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA POLL LYAl --,LAST.FIRST) <br /> (/ "TH (/f 2 o�j PHONE k WITH AREA CODE <br /> NIGHTS' NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> /1 //,�/�# �j� / CARE OF A�RESS INFORMATION <br /> NAME J�a6k l 4N '7 /w (r ��al <br /> ✓Box la dicale ClPARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET D SS 0 CORPORATION Cl LOCAL-AGENCY LFEDERAL-AGENCY <br /> P� 0 U 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIPG�EPHONE p,WI^H AREA ���� <br /> CITU NAME <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME ,/` <br /> a5 <br /> ✓Rox io indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <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. ❑ it. 111.❑ <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 <br /> AGENCY# FACILITY IDN #01 TANKS at SITE <br /> ® d D DUa <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PHO N WITH AREA CODE <br /> 0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE FR=D__F`- <br /> Z3 RECEIPT N /TjB <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) , r <br /> DATA PROCESSING COPY <br />