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STATE OF CALIFOR <br /> WATER RESOURCES CONTR BOARD /`SEP iu,^,%A T,•,,F� <br /> i 1 <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 0 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �40F Tl_,' <br /> MARK ONLY F-1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE R'i <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ACDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET PARTNERSHIP ❑ STATE-AGENCY <br /> +', ORPORATICN ElLOCAL-AGENCY ❑ FEDERAL-AGENC;y <br /> vy � j♦ [] fNDIVIDUAL ❑ COl1N1Y-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> AtvIeC4 CA 3 Cv 24 2 3 <br /> TYPE USINESS: ❑ 2 DISTRIBUTOR F] 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 1 GAS STATION 0 1:13 FARM ❑ S OTHER TRUST LANDS �AT 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 Y WITH AREA CODE <br /> r S7 <br /> NIGHTS: NAME ILASf.FIR PHONE#WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o.S K.EET AD */Box to indicate El PARTNERSHIP 11STATE-AGENCY <br /> U [1 CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP E_ PH NE#,WITH AREA CODE <br /> C4f/� % 3 O <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME . CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Q 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: 1. In It. til. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [Hill LL111 1 11 1 111 (plo011 <br /> CURRENT LOCAL AGENCY FACILITY 19# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIQN CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3. 0 'i YES NO O � sa <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> `iIIIIIJ FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />