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STATE OF CALIFOR -° <br /> WATER RESOURCES CONT�OARD <br /> FORM 'A'N <br /> UNDERGROUND STORAGE TANK PROGRAM =" o <br /> SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z10 <br /> �— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Sz_� <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) v <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Ror to ir4iGle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> f'-1 '1 (�, C -`d G . 1 ❑ M PORATION ❑ LOCAL AGENCY ❑ FRIEML AGENCY <br /> l_.b'-=l �J �+^`�w•�^U ❑ INUNIOUAI ❑ COUNiKAGENp <br /> CITY NAME - STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> LcI � CA H 5 L 4 L <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR Box if INDIAN EPA ID p <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ESERVATION o ❑ AT THIS SITE <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 /> 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 /> MAILING or STREET ADDRESS ✓Bax to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE p,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 NOTIFI#ATION AND BILLING: I. ❑ if. ❑ 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 /> COUNTYTI JURISDICTION N AGENCY N FACILITY ID R N of TANKS at SITE <br /> EE 1 o c) --L 3 k S c O d v <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> Z(lTE 2((-) <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION jCj�OODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED I p <br /> D a �� Uv -4 YES ❑ NO ❑ '3 1 (� L 7 I <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> I'y(� DATA PROCESSING COPY /\J\'/l <br /> U \ <br />