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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <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 all -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (TI <br /> D7 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> i ) -ie y ADDRESS NEAREST CROSS STREET ✓ ro"'. ❑ PARTNERSHIP 0 STATE AGENCY <br /> CORPoRATION ❑ LOCAL AGENCY 0 FEDERAL AGENCY <br /> Cl INDIVIDUAL ❑ COUNT'/-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> 1 PO Iv CA 4 -c�l(oc1 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TA K's <br /> ❑ 1 GAB STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ❑ATION or 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) PHONE N WITH AREA CODE <br /> o Duk - 9 <br /> NIGHTS'. NAME(LAST.FI T) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ aindicale 13 PARTNERSHIP 0 STATEAGENCY <br /> /'� CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> �,) e L(J 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> (Z, N C' S 4�i 26 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> J <br /> MAILING or STREET ADDRESS ✓Box M odicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <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. ❑ If. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> = = = I I I 1176 111 1 1 1 It) <br /> CURRENT L AL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> U ID <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS�T7RACpT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE/-D <br /> `I SU T R 0(] Z I YES NO <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($),UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> FORM A(3-2-88) 1p it <br /> DATA PROCESSING COPY , <br />