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STATE OF CALIFO IA WATER RESOURCES CO OL BOARD ..,/s`��'°'�^;•��� <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> 1O <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER TLV CLOSED SITE 1-+ <br /> ONE ITEM ❑ p INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME , CARE OF ADDRESS INFORMATION to <br /> (��j-'�I/�P( <br /> ADDRESS NEAREST CROSS STREET ✓ Ia imul, 0 PARTNERSHIP 0 STATE AGENCY <br /> 3 CORPORATION 0 LOCALAGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID p <br /> ESE❑ If of TANK's <br /> t GAS STATION [—] 3 FARM ❑ 5OTHER TRUSTVATION LANDSo ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAR NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 9 G3"97 D-- <br /> NIGHTS: NAME(LAST.FIR ) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME f 1 CARE OF ADDRESS INFORMATION <br /> O ' `/ <br /> MAILING m!g�TREET ADD; I/Box to indicate 1-1PARTNERSHIP0 STATEAGENCY <br /> Y O e7X �0 `� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> I J 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> C 19 Cao9 yG3 —4 - <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME �l+�' ^ - CARE OF ADDRESS INFORMATION <br /> W� <br /> MAILING or STREET ADDRESS ✓Box toindicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE».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. ❑ If. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# M of TANKS at SITE <br /> 3 1 d 16 111 1? 161 1 1060 <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE p WITH AREA CODE <br /> EI 33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OAT E FILED QV-V <br /> A O YES ❑ NO <br /> CNECK PERM AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p <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 Y. <br /> �i— FORMA(3-2-81B) <br /> DATA PROCESSING COPY <br />