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STATE OF CALIFORNIA' WATER RESOURCES CONTROLVtARD <br /> gt�� 'tie <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM (% <br /> u t_ �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `+t,.o�,a <br /> MARK ONLY � /NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1+ <br /> ONE ITEM Lids in7ERIM PERMI7 4 AMENDED PERMIT <br /> ❑ ❑6 TEMPORARY SITE CLOSURE W <br /> I. FACILITY/SITE INFORMATION & ADDRESS --(MUST BE COMPLETED) 41 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1► <br /> ADDRESS — <br /> NEAREST CROSS STREET ✓Bwlo#AceM 11PARfNEPSHP 11STA74GM <br /> CITY NAME <br /> /J •, L� O alea5_ El CDD MAID 11 W kLAGDOY 11TDOR L- AGENCY <br /> STATE A <br /> ZIP CODE SITE PHONE k WITH AREA CODE <br /> C <br /> TYPE OF BUSINESS: ❑p DMIVBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID# <br /> ❑ 1 GAS STATION ❑3 FARM ❑5 OTHER RESERVATION <br /> or ❑ #of TAJWs <br /> TRUST AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <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 /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bon to irdIcele 11 PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 13 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate O PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ 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. ❑ 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 e,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m / kHEil I d00 <br /> CURRENT LOCAL AGENCY FACILI� APPROVED BY NAME PHONE#WITH AREA CODE <br /> r_x <br /> PERMIT NUMBER L PERMIT APPROVAL DATE / PERMIT EXPIRATION DATE <br /> �� S <br /> LOCATION CODE CENSUS TRACT* SUPERvis0rISTRICT COW BUSINESS PLAN FILED DATE FILED <br /> YES NO ❑ <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> i <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(3-2-88I <br /> DATA PROCESSING COPY `� \ <br />