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TXI <br /> STATE OF CALIFORNIA WATER RESOURCES CONTRO160ARD «`." 'i"� <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> a Z <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ""."-�e <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION P7"PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE .j p W <br /> Fj <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 4h. <br /> FACILITY SITE NAME rPe,j-�, CARE OFADDRESS INFORMATION <br /> ADDRESS NEAREST <br /> It <br /> /y� ,p 1T— L NEEAAREST CROSS <br /> ySTREET <br /> / ✓Box 10 woe PARTNERSHIP ❑ STATE AGENCY <br /> IY/ I / Foos e Vli I 1 S.T V �Y// GnFI INDIVISt El DUAL El COUNIY AGENCY 0 LOCAL AGENCY ❑ FEDERAL AGENCY <br /> CITU NAME ^, (D r STATCA ZIP C06 a O SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS:)❑T 2 DISTRIBUTOR ❑4 P CESMR I I/Box if INDIAN EPA IDp X 01 TANI <br /> RESERVATION❑ ❑I GAB STATION ❑ 3 FARM 5 OTHEfl TRUST LANDS or AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> ao - <br /> NIGHTS'. NAME(LAST,F^IRSST)p PHbNE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME /� ,A �{., CARE OF ADDRESS INFORMATION <br /> / V / /IC/ C <br /> MAILING or STREET ADDRESS ✓Box io intl r.le PARTNERSHIP ❑ STATE-AGENCY <br /> O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> eOle I t Isf, ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N, ITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> _� O <br /> ✓ <br /> MAILING or STREET ADDRESS BOX 10 RATIte ❑ PARTNERSHIP ❑ STATEAGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDI IDUAL ElCOUNTY-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. II. ❑ 111.❑ <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 At AGENCY# FACILITY ID If #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE At WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PLOCATIONCORDE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDVES � NO <br /> PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT BY. / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br /> w <br />