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ATER RESOURCES CONTROPRARD STATS OF CALIFORNI0 ww. A <br /> V-_4"moi lY.�y-i <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM y � m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `S 10 <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ..r <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Mc db2, i <br /> ADDRESS NEAREST CROSS STREET I/Box to intlicale ❑ PARTNE'E.SHIP ElSTATf-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY F1FEDERAL-AGENCY <br /> l� I � ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Li CA - Czc� <br /> TYPE OF BUSINESS. 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIAN EPA ID II #o1 TANK's <br /> RESERVATION or � AT THIS SITE <br /> 1 GASSTATION 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME{LAST,FlRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I <br /> Y2QK <br /> ✓ <br /> MAILING or STREET DDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> t, ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> l <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-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. 5z Ill. El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> LL I LLI � 6 1(9 1--+ l L 1 1 14 11 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> TRICT CODE BUSINESS PLAN FILED DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT i <br /> G YES NO ® l I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED 6Y AT LEAST1I OR MORE TANK PERMIT FO R M 'B'APPLICATIONI UN L SS THIS IS A CHANGE OF SITE INFORMATION ONLY.C <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY \ <br />