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STATE OF CALIFORNIA WATER ESOURCES CONTRO OARD <br /> � f <br /> FORM A: UNDERGROUND STI RAGE TANK PROGRAM <br /> 0 7 <br /> SITE , FACILITY/SITE, INFORMATI N and/or PERMIT APPLICATION , <br /> P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C\!PORN <br /> WA PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE �* <br /> MARK ONLY NEW PERMIT —13 RENE L E ❑ ❑ <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �/ <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDF ESS INFORMATION <br /> ADDRESS NEAR ST CROSS S_REET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL-Q-GENCY <br /> � Ml� [T ❑ INDIVIDUAL ❑ COUNTY-AGENCY t <br /> ( '✓ <br /> CITY STATE ZIP CODE SITE PHO E#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 110 # _ #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM <br /> 5 OTHER RESERVATION or ❑ `� AT THIS SITE <br /> LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. 44AME(LAST,FIRST) PHONE#WITH AREA CODE <br /> f�/lh iq K �- 'T S J/A fA <br /> NIGHTS: NAME(LAST,FI ST) PFIONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ONE#WITH AREA CODE <br /> �1A f1A I S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE FADDRESSINFORMATION <br /> MAILING or STREET ADDRESS�. ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> DG, D El INDIVIDUAL <br /> 1:1 LOCAL-AGENCY F DERA - GENCY <br /> ,y2— VT i(.Ct' x I�1/l(j� INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE / PHONE If,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME - �,�.� ' D CARE OF ADDRESS INFORMATION <br /> !✓ 'r, <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE US D FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER URY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FNUMISER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> D0 7 Lo o <br /> ENCY FACILITY 10# APPROVE BY NAM PHONE#WITH AREA CODE <br /> E <br /> EE] <br /> PERMMIIT APPROVAL ATE P R T EXPIRATION DATE <br /> CENSUS TRAACTT# P VISOR-DIGICT CODE BUSINES YES NFILED N / TE FI D`3'LJ �f1p 81-7PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 />