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STATE OF CALIFORNI19 WATER RESOURCES CONTRCGOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u +fie <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °+t�Foax�n <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT FS rCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE [7� <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> 7 /SIT N E CARE OF ADDRESS INFORMATION <br /> ADDRESS N EST CROSS STREET ✓BOXIO Qi 13 PARTNERSHIP ElSTATE AGENCY N <br /> ❑ COWORAPON ❑ LOCAL AGENCY ❑ FEDERA,AGENCY <br /> ❑ INDIVIDUAL ❑ 000N1Y.AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 426 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID * <br /> ❑ 1 GAS STATION ❑3 FARM �OTHER TRUSTLANDS or ❑ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA (LAST,FIR1ST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> a <br /> MAILING or STREET AD ORES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ ERA - GENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA STATE ZIP CODE PHONE If,WITH AREA CODE <br /> tAJXNV Sl 08- ,2 <br /> III. TANK OWNER NFORMATION &ADDRESS— (MUST BE COMPLETED) Noss) -735- 19 -1 1 <br /> NAME CARE OF ADDRESS INFORMATION <br /> S I <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. Rr 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION If AGENCY* FACILITY ID* *of TANKS at SITE <br /> o 2- 1 d d <br /> CURRENT LOCAL AGENCY ACILITYID* APPROVED BYNAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER JJ`` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVI8O -/DISTID T CODE BUSINESS PLAN FILED DATE FILED cam/ <br /> © .23A a V L YES NO-E— <br /> CHECK* 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 INFORMATI' <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />