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STATE OF CALIFORNO WATER RESOURCES CONTRIPLOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM _ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONm <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT A�'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYrLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 <br /> FAi NAME V I I�I1 CARE OF ADDRESS INFORMATION <br /> ADDRESS , NEAREST DRO ST EET ✓Box to lMicale ❑ PARTNERSHIP ❑ STATE AGENCY N <br /> I, OAPOEATION D LOCAL AGENCY Cl FEEBAL AGENCY ((� <br /> (�. V iNDZDU" ❑ COUN7AGENCY <br /> CITY NAMF. 1 I STATE ZIP CODE SITE PHONE k,WITH AREA CODE do <br /> _aCN( CA 4100 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID 1 #of TANK's <br /> RESERVATION or AT THIS SITE I <br /> ❑ 1 GAG STATION [:] 3 FARM ®'5 OTHER TRUST LANDS ❑ �!° <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS(LAST,FIFISST,L PHO]N,,E�tt(W�ITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE ft WITH AREA CODE <br /> LEI— - 1—�� <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME �� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET A DRES ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> NDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME Y STATE ZIP CODE PHONE 1,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME I <br /> CARE OF ADDRESS INFORMATION <br /> P- -L rl <br /> MAILING or STREET ADZ / ✓Box to indicate ❑ PARTNERSHIP D STATEAGENCY <br /> CORPORATION D LOCALAGENCYD FEDERALAGENCY <br /> NDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME /I STATA ZIP CODE PHONE N.WITH AREA CODE <br /> o d I lit�- o <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. ❑ )1. Nr 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# JURISDICTION Is AGENCY# FACILITY ID It #of TANKS at SITE <br /> EE 10101 / JS­15� ,31 101010111 <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CCON CODE CENSUSSTRACT# SUPERVODTRICT CODE BUSINESS PLAN FILED DATE <br /> TTEE <br /> FILED <br /> Z 2 CTGO YES NO.Q— <br /> ECK# <br /> 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 IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> • DATA PROCESSING COPY • <br />