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STATE OF CALIFORNIAP WATER RESOURCES CONTRO OARD '""'•.' E <br /> I m IN n <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SJT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY F-1I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - (� <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boxb idigle 0 PARTNERSHIP 0 DTAT&AGENCI' <br /> ,I�� +VL 0 COWORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> J,zm (/(/u 0 INDIVIDUAL 0 C11UMY-AGENCY <br /> I dnla� ;?_­_-CITY NAME / STATE ZIP CODE''")/'1 SITE PHONE N,WITH AREA CODE <br /> CA O20 5 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P5rkSSOR ✓Box it INDIAN EPA ID N ,(N r N of TANK'F / <br /> ❑ 1 GAS STATION ❑ 3 FARM THS+ TRUSESETYLANDS 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#WITH AREA CODE <br /> — ' 3yAu blu rtCady 9y6 767 <br /> NIGHTS: NAME(LAST,FIRSTQ) �j �� p PHONE p WITA AREA CODE NIGHTS: NAME(LAST.FIRSST)��� p PHONE p WITH AREA CODE <br /> SCV-/ nt„ <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS A/Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to iindicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID N N of TANKS N SITE <br /> 0 161l910101 Z <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBIPERMIT <br /> PERMIT APPROVAL DATE rtRM1T EXPIRATION DATE <br /> LOCATION COT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> 2 l YES NO p� ^ <br /> cJ OS <br /> CHEC NNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOAWANIED BY AT LEAST IQ OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) ' • <br /> \I <br />