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STATE OF CALIFORNIV WATER RESOURCES CONTRtBOARD <br /> f yEP f'�[k•�T�` <br /> W; <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM "gym <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b ! <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FARK70NLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITEEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE gm <br /> r <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION O <br /> CG i <br /> ADDRESS <br /> �J ! , ! / '/ NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> (��� S. W (7Lx't, L'Val ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA �jZ� <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUSRVLANDS TION or ❑ #of TANK's �J <br /> AT THIS SITE <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) PHONE#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 /> ( eGly] <br /> MAILING or STREET ADDRESS j t/Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> I �� ��v, /.V4 El CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> W ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> A�� %�- C7 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME / <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET/ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �� <br /> Ji^7 El CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ` ( &v 1&1 ❑ 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. 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Tl Fo7o7i 3 o 151 1 1 1 124 <br /> [PERMIT <br /> NT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> NUMBER PERMIT APPROVAL DATEEXPIRATION DATE <br /> ION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# gY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1MORE TANK PERMIT FORM `B'APPLICATI ), UNLHIS IS A CHANGE OF SITE INFORMATION ONLY. ,�\� <br /> FORM A(3-2-88) <br /> ®� DATA PROCESSING COPY <br />