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STATE OF CALIFORNIA WATER RESOURCES CONTROAARD <br /> A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM yY" a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT .®"5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -y <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) t <br /> FACILI /SIT NAME CARE OF ADDRESS INFORMATION <br /> C L a ri I ecck <br /> ADDRESS .Jr� <br /> NEAREST CROSS STREET ✓Bmloinalcele 1:1 PARTNERSHIP ElSTAiE-AGRJp <br /> S _� ❑ CORPORATION -C EOCALAGENCY ❑ FEDERAL AGENCY <br /> m4xi ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAM STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑�L�4.�PR,OCESSOR ✓Box it INDIAN EPA D ft <br /> ft �Q <br /> ❑ f GAS STATION ❑ NK <br /> 3 FARM L�.S""'HER TRUSRESETLANDSVATION o ❑ / ! fAT <br /> oiT ISISl/ THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> Dk NAME( ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIG AME(LAST FI ST <br /> PHONE ft WITH AREA( CODE NIGHTS: NAME LAST,FIRST)) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM fir. // 41CARE ADDERS FC9M Z <br /> ^ <br /> MAILp,STR TADD SS I/Sir.to Indicate U PARTNERSHIP El STATE-AGErfCY <br /> ElCORPORATION ISk-MCAL-AGENCY ❑ FEDERAL-AGENCY <br /> x ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE /( <br /> c 6 3 JU <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILIN or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITU NAME STATE ZIP CODE PHONE p,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.� If. ❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = CLCD C M q <br /> CURRENT LO A A EN FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT IF SUPE RVISO ST ICT CODE BUSINES,PLAN❑FILED NO DAT FILED <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> Lff <br /> I 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(3-2-88) • <br /> DATA PROCESSING COPY • <br />