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STATE OF CALIFORNINO WATER RESOURCES CONTRO.OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I <br /> e COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANEENN CLOSED SITE I"& <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ✓ I-4'� <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ESCA&u P Q <br /> ADDRESS (� NEAREST CROSS STREET ✓ 'dome ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 7� MCA/ /L/r <br /> CORK RATION ❑ LOCA AGENY ❑ EGEA4LAGENIX <br /> IG /TrG INGNIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE TE PHONE N,WITH AREA CODE <br /> E CA 53 2U 09 3/3 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PNQESSDR -/BOX A INDIAN EPA ID R #OITANK's <br /> RESE <br /> ❑ 1 GAS STATION F__] 3 FARM OTHER TRUSTYLAN S Or F-1 �L AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME LA T,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> .Yirir+, toy 57/-�fl� <br /> NIGHTS: NAME(LAST,FIRS ONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> E ❑ CgOPeRATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE A,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS' ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D 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: 1. 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 M JURISDICTION N AGENCY# FACILITY ID If #of TANKS at SITE <br /> = <br /> CURRENT LOCAL AGENCY <br /> FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> [CgHECK# <br /> PPROVAL DATE PERMIT EXPIRATION DATE <br /> SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILE <br /> YES NO 'J 1 <br /> SURCHARGE AMOUNT FEE CODE RECEIPTk 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 /> • DATA PROCESSING COPY <br />