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STATE OF CALIFORNIP WATER RESOURCES CONTRPBOARD <br /> SE's �Me <br /> y A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° A,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> IV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> O,Q �71A/ Ov <br /> ADDRESS NEAREST CROSS STREET ✓Eatioloolt ❑ PARTNERSHIP STATE AGENCY <br /> ❑ CORPORATIGN ❑ LOCALAGENCY ❑ FEDEMLAGENCY <br /> ❑ INDIVIDUAL ❑ COUNT/AGENCY <br /> CITY NAME L STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> /C SO 1 CA S;o1/3-;iV <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PR R ✓Box if INDIAN EPA ID NESE <br /> ❑ I GAS STATION L]3 FARM OTHER TRUSTY <br /> LANDS ATION or ❑ AT TI BITE U <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 <br /> Yv c7� `���3S <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 /> a2fN L�9Cir Yov1 f 2� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> QJ- 4 <br /> � Nv� 11INDIVIDUALON Cl COUNTY AGENCY ClFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 4/ � yaa <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREBB 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 /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION k AGENCY R FACILITY ID R R of TANKS at SITE <br /> 39 I = = I I I / E= I I I lY <br /> CURRENT LOCAL AGENCY FACILITY 10 M APPROVED BY NAME PHONE N WITH AREA CODE <br /> 9UD/�f' 76 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> CENSUS TRACT M SUPERVISOR•DIS RICT ODE BUSINESS PLAN FILED DATE FILE <br /> d3. YES NO F-1 <br /> / (� <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: /Ll ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 3 DATA PROCESSING COPY • <br />