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STATE OF CALIFORNIA WATER RESOURCES CONTROLINOARD ' <br /> A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> PARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO TE F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE � <br /> W <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) Q <br /> O <br /> FAG TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> is Yna r <br /> ADORERS / NEAREST CROSS STREET ✓BmbibirAV ❑ PAUNMIP ❑ STATE AGFNLY <br /> /_ t ,l/I /I ❑ TION OM,QN,Y ❑ <br /> ❑ RSEAILAGDKY <br /> CITY NAMES+� STATE ZIP CODE rY SITE PHONE N,WITH AREA CODE <br /> T cA �I a-q(fy <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bw if INDIAN EPA ID N N 01 TANK'N <br /> RESERVATION or <br /> ❑ 1 GASSTADON ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) j <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: "ME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> MAILING or TREET ADDRESS IoOicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMI STATE ZIP CODEO RHONE#,WITH AREA CODE /3 <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or ST ADDRESS ✓Box to mdicale ❑ PARTNERSHIP ❑ STATE-AGENCY <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)BOK 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION R AGENCY N FACILITY ID E N of TANKS at SITE <br /> CURRENT LOCAL AGENCY PACK. APPROVED APPROVED BY NAME PHONE N WITH AREA CODE <br /> IG 5 <br /> PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ELOCATIONCENSUS TRACTN SUPERVISOR-DIST111GT CODE BUSINESS 7:��j <br /> DATE FILED1113. U Ymw -" �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> AIr DATA PROCESSING COPY %E/ <br />