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STATE OF CALIFORNIA WATER RESOURCES CONT <br /> FORM 'A': R�BOARD /. e <br /> SITE UNDERGROUND STORAGE TANK PROGRAM FACILIT <br /> TY/SITE, INFORMATION and/or PERMIT APPLICATION Ic <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE I <br /> c9LIFOP N'P <br /> MARK ONLY ❑ 1 NEW PERMIT Lj 3 RENEWAL PERMIT <br /> ONE ITEM CHANGE OF INFORMATION 7 PERMANENTLY CLOS SITE <br /> 02 INTfA <br /> ERIM PERMIT 0 N AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> ti <br /> FACILITY/SITE AME <br /> CARE OF ADDRESS INFORMATION <br /> 20 Com - s� <br /> ADDRESS <br /> /(P/72 (L/ /14 Pj • NEAREST CROSS STREET ✓ iAfmW El PARTNERSHIP 1-1 STATE <br /> AGENCY� <br /> r/ CORPORATION ❑ LOCAL-AGENCY ElD <br /> FEDERAL A <br /> CITY NAME ❑ INDIVIDUAL 13COUN7YAGENCY AGENCY <br /> STATE ZIP CODE SITE PHONE#y,WITH AREA CODE <br /> TYPE OF BUSINESS: � 2DISTRIB OR 04 PROCESSOR ✓Box if INDIAN EPA 10 Ir .5..3 (] <br /> I GAS STATION 3 FARM OTHER ESERVATION or <br /> USTLANDS El #oi TANK' <br /> TR / <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST FIRST PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: N E ILA T.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> '1 ✓Box U 1-,mcale ❑ PARTNERSHIP ElSTATE-AGENCYC ORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME DIVIDUAL 13 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK O ER INFORMATION & ADDRESS — (MUST BE COMPLETED) Z33 <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box rointlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FTATE-AEDIERALTATE-AGENCY <br /> Y <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 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. it. 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACI k <br /> 3 � � #of TANKS BI SITE: mm <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> K N PPROVED BY ME PHONE N W ITH ApEA CODE <br /> PERMIT NUMBER P <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE <br /> BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT <br /> FEE CODE RECEIPTN B <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 /> FORMA(3-2-66) Ift <br /> DATA PROCESSING COPY <br />