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irSTATE OF CALIFORNIJr WATER RESOURCES CONTRO'L'EIOARD c `^A <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM '� • <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONZ <br /> J`­d7 COMPLETE THIS FORM FOR EACH FACILITY/SITE I <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 7PERMANENTLYCLOSEDSITE r <br /> ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I71 SSiD <br /> ADDRESS /;D7 <br /> /'7 NEAREST CROSS STREET ✓goe Pordic ElPARiNEAGXIP ❑ SIAIE.gGENC1 <br /> CITY NAME <br /> 1:1CGRPQR TION ❑ LOCALMIP 11 RDBVLAGBICY <br /> El worvlDU4 ❑ CDLN'1Y-AGENp <br /> STATE ZIP CODE <br /> 1 SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box 6INDIAN EPA ID p <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS SERVATION or If of TANKs <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH <br /> AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to mclicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE 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 ✓Boz to,nd.cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 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 NOTIFICATION AND BILLING: L ❑ 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Y JURISDICTION M AGENCY M FACILITY ID M M of TANKS at SITE <br /> 10131 / BE3 O <br /> CUR ENT LOCAL AGENCY FACILITY IDM D BY NAME PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRAT16NDATE <br /> LOCATION CODE CENSUS TRACT p SUPEI{VISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED I <br /> 3 3 /(J LTJ /( YES NO <br /> CHECK 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(8-2-88) <br /> DATA PROCESSING COPY J <br />