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STATE OF CALIFORNIA'S WATER RESOURCES CONTROLOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - � 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE _ <br /> c'QLIFORHiP. <br /> MARK ONLY ❑ 1 N ERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> El 4' vi <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ENEARESTGROSS STREET V e ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL�AGENCY <br /> INDIVIDUAL ❑ COUNTti'-AGENCYGITY NAME ZIP CODE SITE PHONE il,WITH AREA COD€ <br /> .�33 n <br /> IGTYPE OF BUSINESS: �g DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID ;a <br /> ASSTATION 0 3 FARM 5 OTHER STRESE LANDSATION or 0 k of TANK'. <br /> AT THIS SITE ,3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> l%_ �-D zzz '45� Z-69n 57� <br /> NIGHTS: fME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAS .FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME- CARE OF ADDRESSINFORMAT}ON <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �f tt ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME v STATE ZIP <br /> �C^ODE PHONE fl,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME11,21 1 CARE OF ADDRESS INFORMATION <br /> MAILING or STREADDRES ✓Elindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> r o ORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> LJ INDIVIDUAL ElCOUNTY-AGENCYCITY NAM�CEj� STATE ZIP CODE .PHONE 0.WITH AREA CODE <br /> C7�4� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. <br /> THIS FORM!-IAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S 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 /> L�LLQ I 1 1:1 Li F1 I / Lok) _F�) <br /> CURRENT LOCAL AG CY FACILITY k APPROVED BY E <br /> �•/��,�y � PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE IT XPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k UPER ISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �-� YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY- <br /> FORM A(3-2-88) 10 <br /> DATA PROCESSING COPY Q 5- <br />