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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD <br /> 1 f <br /> FORM A: ` <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 CLOSED SITE I� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 C� <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CTI <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 00 <br /> IA4F <br /> ADDRESS / NEAREST CROSS STREET ✓BWIOitlrJN ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 0 \ 1 W ❑ WBPJ141nDN ❑ LDCAIAGENLY ❑ RIDEMLAGENCY <br /> ft <br /> V ❑ INDIVIDU ❑ WUNIY-AGENCY <br /> CITY NAME STATE ZIP CODE / SITE PHONE N,WIT AREA CODE <br /> S ll�a CA '?-�5 2• -'��6- 0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 ESSOR ✓Box it INDIAN EPA ID N <br /> ❑ T GASSTATION 3FARM SOTHER RESERVATION or - #OI TANK's <br /> ❑ TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM�LAST,FIRST) O <f (LAST PHONE Of WITH ARE+COODE� DAYS N& R� � NE p WITH AR'lD <br /> NIGHTS. NAME(LAST,FIRST) �� PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE N6WITH'AREA/7CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME , CARE OF ADDRESS INFORMATION <br /> cMr- �,� -r/?Oe-k5 <br /> I <br /> MAILING or STREET ADDRESS /,"//'� //'�7 �/ ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCCI Y <br /> • 1 •" d ^ ❑ INDIVIDUAL <br /> ❑ COUNTY-AGENCY <br /> 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREACODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓box to inrlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. FP1 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY B FACILITY ID# #of TANKS at SITE <br /> 1�uj = 1 as 1 1 5, q6 1010101 <br /> CURRENT LOCAL AGENCY fjkCILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> 6m ,y <br /> PERMIT NUMBER PERMIT APPROVAL DATE F/ PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# q SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Or BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-81 <br /> DATA PROCESSING COPY • / <br />