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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM � �o <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION IQC1A, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE — <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (.',,��-) 2: <br /> 10 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACI TY/SITE AVE CARE OF ADDR S INFORMATIONale �� <br /> s <br /> ADDR S i _� NEAREST CROSS STREET ✓90 RATIO ❑ PAPAL AGEN ❑ STATE FEDERAGENCY <br /> /r/``/- OVIDUALIOA ❑ LOCAL AGENCY Cl FEOEPAL-AGENIX a) <br /> ❑ IRlnviouAt ❑ couenaGENa �a�w <br /> CITY NAME — STATE ZIP CODE SIT ONE p,WITH AREA CODE W <br /> CA �/ J <br /> TYPE OF BUSINESS 2 DISTRIBUTOR ❑ 4 PROLE ✓Box it INDIAN EPA ID a If of TANK's <br /> RESERVATION or ❑ ATTHISSITE <br /> F-] 1 GAS STATION ❑ 3 FARM HER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONEp WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> DAYS. NAME(LAST.FIRST) 77SV <br /> NIGHTS'. NAME(LAST,FIRS PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME S �� <br /> MAILING or STREET ADDRESS ✓Bax to Indicate Ll PARTNERSHIP F1 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE ti,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS -/Box to indicate El PARTNERSHIP LlSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a AGENCY# FACILITY ID If #of TANKS at SITE <br /> E7 7 lol d v 1 / <br /> CURRENT L CAL AGENCY FACIL17 ID It <br /> APPROVED BY Iii PHONE#WITH AREA CODE <br /> i Q <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE IT EKPIRA DATE <br /> LOCATION CODE CENSUS TRACT p SUPERVI OR-DISTRICT CODE BUSINESS YPELSN FILED NO ❑ DATE FILED /a <br /> D 3 .? a <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p V: <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) • S <br /> DATA PROCESSING COPY <br />