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STATE OF CALIFORNIP WATER RESOURCES CONTROL 0ARD <br /> W <br /> f Y u'nom- _ - FIA <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cy�,Fp RN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE )"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� CD <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �b w ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY Q�Cu INDIVIDUAL [ICOUNTY-UNTY-AGENCY <br /> CITY NAME STATE ZIP ODE SITE PHONE#,WITH AREA CODE <br /> C)d.-`- CA to 3(p- q&3 i <br /> TYPE OF BUSINESS: p DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID # / #of TANK's f <br /> ❑ ❑ RESERVATION or / AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARMOTHER TRUST LANDS ❑ / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST_RST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSR ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> [:1 CORPORATION ❑ LOCAL-AGENCY ❑ 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 El PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl 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. �' II. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® <br /> Ec D �: 3 D C1 u . <br /> CURRENT LOCAL AGE11NCCCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> I C <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAC FILED (� <br /> 1 YES ❑ NO ❑ 1 (3 11 . 2- <br /> -7 '� 9 <br /> 419 <br /> CHECK# PERMIT AMOUNT VV 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 INFORMATIO Lif. <br /> FORM A(3-2-88) <br /> l0 0 <br /> DATA PROCESSING COPY <br />