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STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD <br /> P �S <br /> i A <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM roo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMA,R,K ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �� W <br /> 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> N <br /> FACILITY/SITE AVE �r CARE OF ADDRESS INFORMA�q N <br /> my S u I 1 1�1 1 Q -oe. iS I S h <br /> ADDRESSNEAREST CROSS STREET ✓90 10iAlsle Ill PARTNERSHIP C STATE AGENCY <br /> IA ON El LOCAL AGENCY ❑ FEDERAL AGENCY <br /> V� 1L� ❑ INOIVIOUAL ❑ COUNTY-AGENCY <br /> CITY NAME 51,Cj STATE ZIP ODE_ SITE PHONE#,WITH AREA CODE <br /> rCASJ a <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓DO.if INDIAN EPA ID # <br /> RESERVATION or - �_ #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM �3'0'fIlER TRUST LANDS El AT THIS SITE I <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 /> I <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> i C +rnen+ u r k-- <br /> MAILINGorSTREETADDRESS ✓B to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 2 CORPORATION C LOCAL-AGENCY C FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME /1, � I kb� STATS^CCZIq DE '20:2- <br /> PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE CO_wM-P.LETED)5 <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE CODE P <br /> ZIP HONE#,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. Q'lI. ❑ if. ❑ <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 If AGENCY# FACILITY ID It #of TANKS at SITE <br /> 00 1 2- 1 °( I 2 I O 1 Oo <br /> CURRENT LOCAL AGENCY FACILITY ID Al APPROVED BY NAME PHONE If WITH AREA CODE <br /> —iO <br /> se <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (' <br /> 3 oV YES NO <br /> IC HECK# 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(3-2-86) <br /> 0 DATA PROCESSING COPY 0 <br />