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STATE OF CALIFORNIA WATER RESOURCES CONTRONOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Q �" <br /> SITE A FACILITY/SITE, INFORMATION and/or PER IT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE 4i, o� <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATIONOe <br /> ONE ITEM 2 INTERIM PERMIT 7 PERMANENTLY CLOSED SITE <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 6 Z <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> ®R Q — CARE OF ADDRESS INFORMATION <br /> 1 RLrn) G <br /> ADDRESS <br /> NEAREST CROSS STREET ✓gp,loauie C PARTNERSHIP C STATE AGENCY <br /> 7 /I'n//U( IJ ❑ CORPO ATIM Cl LOCA-AGEICY ❑ FEDERAL- <br /> AGENCY <br /> CITY NAME C INDIVIDUAL C CDUNTY AGENCY <br /> STATE ZIP CLOS SITE PHONE A.WITH AREA CODE <br /> TYPE OF BUSINESS: �2 ISTRIBUTOR 4PROCESSOR ✓Box if INDIANEPA DA CJ <br /> I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ F of TANK'F ' <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST� PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE CO <br /> NAME MPLETED) <br /> Sa AV'✓lK n CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS jo/Box to intlicale PARTNERSHIP <br /> CORPORATION C LOCAL-AGENCY C STATE-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCYCFEDERAL-AGENCY <br /> ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> Box to intlicale ❑ PARTNERSHIP <br /> ❑ CORPORATION LOCAL-AGENCYCSTATE-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY ❑ FEDERAL-AGENCY <br /> CITY NAME AGENCY <br /> 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: I. it. 111. <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> R <br /> JURISDICTION S AGENCY M FACILITY ID M Mol TANKS BI SITE <br /> Q� v <br /> AGENCY FACILI/TY IDNAPPROVED BY NAMEDSL , &9 rJ _—A PHONE N WITH AREA CODE <br /> �V lPERMIT��APPPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED-z 7 Z 3 � DATE FILED <br /> lJ YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> 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 /> FORM A(3-2-88) 0 <br />