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STATE OF CALIFORNIA. WATER RESOURCES CONTROL LiOARD aF <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM = � �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �j COMPLETE THIS FORM FOR EACH FACILITY/SITE C9�IFORN\% <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lj�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS f / NEAREST CROSS STREET ✓Box loidicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> I�iA i�Q ❑ CORPORATION El LOCAL-AGENCY ElFEDERAL-AGENCY <br /> Q l P'T 1 ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME i+ STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 3 27 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCEStOR ✓Box if INDIAN EPA ID a #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETVATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHON #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 13 its( Ne5 2—b �9 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Ste' <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME - 'A^ CARE OF ADDRESS INFORMATION <br /> I m �� K <br /> MAILING or STREET ADDRESI , ✓Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY <br /> r O , /LU�{ I �,y ElCORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ��/ /s 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 1 1 �p STAT ZIP CCE PHONE WITH ISR CODE ,� <br /> -65 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) .�G,,((JJrr ((� Z <br /> NAME CARE OF ADDRESS INFORMATION <br /> G7.4- <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 H,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. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> LMAP-<5 w S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> r5 07 <br /> - <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 01 7,4 Q YES ❑ NO ❑ <br /> CHECK# PERMIT AM UNT 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 />