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STATE OF CALIFORNIA WATER RESOURCES CONTROSEP ai"�f <br /> ARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> X44 Fon N,P <br /> COMPLETE THIS FORM FOR EACH FAC LITY/SITE <br /> F—� <br /> F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE IV <br /> MARK ONLY <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) C-n <br /> CARE OF ADDRESS INFORMATION <br /> FFACILITYISITE NAME <br /> � US <br /> NEAREST CROSS STREET ✓Dmlo ndcak 0 PM�,PSHIP ❑ STATE AGENCY <br /> SS // 0 COIPORATION C3'EECALAGENCY 0 FEDERAL AGENCY <br /> S 0 INDNIDUAL Cl COUNTY AGENCY <br /> AME STATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> CA2U oF BOBINESS: ❑2 DISTRIBUTOR ❑ 4 PRO R ✓Rax A INDIAN EPA IDN M p1 TANK's <br /> OTHER RESERVATION or ❑ AT THIS SI <br /> ❑ 1 GAS STATION ❑3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FI T) <br /> PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /' I CARE OF ADDRESS INFORMATION <br /> MAILING orS ET ADDRESS ✓Ron to indicate ❑ PA HIP ❑ STATE-AGENCY <br /> /�� 0 0 CORPORATION CAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL FL COUNTY-AGENCY <br /> GENCV <br /> CITY NAME STATE ZIP CODE PHONE N.WITH Aw ODJ �J/ <br /> 64- <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <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. ❑ IL III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DArE <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION N AGENCY R FACILITY ID If It of TANKS at SITE <br /> Fp-F O o 03 <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> APPROVED BY NAME PHONE N W ITH AREA CODE <br /> PERMIT NUMBER / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS ACT N SUPERVISOR-DISTRICT DE BUSINESS PLAN FILED DATE FILED �y <br /> 3 a6L YES NO 7 0 <br /> CMECKk PERMIT AMOUNT SURCXARG AMOUN FEE CODE <br /> RECEIPTM Yo :IA. <br /> J 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 /> Q'1 ,FORMA(3-2-88) go <br /> DATA PROCESSING COPY <br />