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STATE OF CALIFORNIA9 WATER RESOURCES CONTROL 10ARD <br /> 5f,'iu axe ?�A <br /> FORM 'A': ..' <br /> UNDERGROUND STORAGE TANK PROGRAM ^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> Z COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT []3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 1"� <br /> ONE ITEM 2 INTERIM PERMIT 0 q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME N <br /> u . u C^ CARE OF ADDRESS INFORMATION <br /> l JC��DQD ¢ l/� <br /> ADDRESS <br /> NEAREST CROSS STREET Box to 0 PARTNEPSHIP 0 STATE AGENCY <br /> C-� O ,L""_ 1 �� � ❑ CORPORATION ❑ LOCAL AGENCY 0 FEDERAL <br /> CITY NAME w V Cl INDIVIDUAL ❑ COUNN-AGENCY <br /> STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> CA <br /> TYPE DF BUSINESS: � 2 DISTRIBUTOR q PROCESSOR ✓Box if INDIAN EPA ID At <br /> E] 1 GASSTATION Ej 3 FARM 5 OTHER RESERVATION orTRUST LANDS AT THIS SITE <br /> ❑ B of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYSEMERGENCY CONTACT PERSON(SECONDARY) <br /> : NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> WI <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) PHONEk WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE it WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP <br /> 0 CORPORATION 0 LOCALAGENCY0 STATEAGENCY <br /> CITU NAME Cl INDIVIDUAL ❑ COUNTY-AGENCY 0 FEDERALAGENCYSTATE ZIP CODE PHONE A.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. 11 it. 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION k AGENCY M FACILITY ID M <br /> Bol TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME U <br /> PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE t <br /> PERMIT EXPIRATION DATE <br /> LOCATCQFEE DE CENSUS A TO SUPER -�I CT CODE <br /> IBUSINESS PUN FILED p ILED <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT O <br /> CODE YES [E:]RECEIPTM IN BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> RM A(3-2-88} <br /> 1 'a'� DATA PROCESSING COPY L <br />