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-sF, <br /> STATE OF CALIFORIW WATER RESOURCES CONTMOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ""� / ' 50 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E—] 7 PERMANENTLY CLO <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESSp I NEAREST CROSS STREET ✓Bo,to Nrale D PAMNERSHIP D STATE AS NLT N <br /> CORPD7� �. ��E'S 1n ❑❑ oruLloN El LoxkA [3 FEDFRAACENc NINDIVID11A! D COUNIAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> CA 3 2 3 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID a a of TANK'a <br /> RESERVATION or AT THIS SITE <br /> E] 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE S 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 /> MAILING or STREET ADDRESS ✓Box to Nmcale D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to mmcate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONES,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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY a FACILITY ID a a of TANKS at SITE <br /> 3g = 2 -Z I I 1 101 <br /> CURRENT LOCAL AGENCY ACILI ID a APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /y Q <br /> LOCATION CODE CENSUS TRAC�T—S^ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G L <br /> YES NO 90 <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT S <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) ) -lb <br /> 4t I <br /> r1 '� 1 DATA PROCESSING COPY . ' d <br />