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STATE OF CALIFORNIA• WATER RESOURCES CONTROLIOARD /. ..e <br /> LEpI Of �4\ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM At Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 1 10 <br /> IC COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION 1-1 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C/ N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> f4 <br /> ADDRESS NEAREST CROSS STREET ✓ Parale Cl PARTNERSHIP ❑ STATE AGENCY <br /> CORPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCYC/ ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME �,f STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> /�iYv� CA 5.�� �S <br /> TYPE OF BUSMESS. ❑ 2 DISTRIBUTO E:] 4 PRGCE ✓Box it INDIAN EPA ID # <br /> ❑ T GASSTATION ❑ 3 FARM ER TRUSTRESEMLANDS ATION O ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> awl <br /> NIGHTS'. NAME(LAST,FIRST) - PHONE If WITH AREA CODE NIGHTS: NAME NAST,FIRSTJIPHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓PRO.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> OCv S — �204� A <br /> MAILING or STREET ADDRESS ✓Bo indicate 11 PARTNERSHIP 11STATE-AGENCY <br /> RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ( V (/ ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME ��, STATE ZIP CODE T P ONE#,WITH AREA CODE <br /> - C� 7b azzll - <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> i <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION 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 /> COUNTYAl JURISDICTION# AGENCY N FACILITY ID# N o/TANKS at SITE <br /> o I ! o <br /> CURRENT LOCA <br /> /L/AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATION CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> / 0 G��./ YES ❑ NO �U <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# /by: <br /> IIIIITHIS 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 /> ORM A(3-2-88) 41 <br /> / DATA PROCESSING COPY <br />