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STATE OF CALIFORNIP WATER RESOURCESCONTROL41OARD <br /> FORM 'A'- UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /FACILITY/SITE, INFORMATION and/or PERMI PPLICATION } / M <br /> COMPLETE THIS FORM FOR EACH FAC /SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY TE IV <br /> D <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 01 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to indimle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> Ax`L(/ K ,20 ❑ INDIVIDUAL ❑ COUNWAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> 703 <br /> TYPE OF BUSINESS: ❑ 23I TOR ❑ 4 PROCESSOR ✓Goxil INDIAN EPA ID # <br /> RESERVATION or #ai TANK's <br /> E:] 1 GAS STATION 3 FARM E] 5 OTHER TRUST LANDS ElAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> P . <br /> Pe mr 6 U - U�- y -:5-4NIGHTS: NAME(LA FI RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tomcicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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 ✓Box io,,dcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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. IE ❑ 111. 1-171 <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# JURISDICTION If AGENCY# FACILITY ID If #of TANKS at SITE <br /> �J 0 1 CG I /�= 6 1 0 1 o a <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 7 <br /> PERMIT INILIMPWIER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECLK# <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �. YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BYa // �� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLES IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-U88) 1� <br /> n��1 G, ^ (�{ �^L,10 Nv • DATA PROCESSING COPY �\\ <br />