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- P <br /> E <br /> 72 <br /> .. M <br /> STATE OF CALIFORNIA WATER RESOURCES CONTR B <br /> bP. ,SA <br /> FORM `A': �m <br /> UNDERGROUND STORAGE TANK PROGRAM =� fto <br /> SITE /� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r o <br /> l_/� COMPLETE THIS FORM FOR EACH FACILITY/SITE C4�)FOR" <br /> F <br /> ARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANE SED SITENE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILI S TE NAME. CARE ADDRESS INFORMATION <br /> ADDRESS NEA EST CROSP STREET ✓ )o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (/ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME : STATE ZIP C09E SITE PHOiNE#,WITH AREA CODE <br /> �JGC�t CA D <br /> TYrlGl <br /> BUSINESS: F-12 DISTRIBUTOR ❑4 PROCESSOR SBox if ERVATION INDIAN EPA ID# #of TANK's <br /> S STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EME GENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST,FIRST)6 PHONE#WITH AREA CODE DAYS: N ME(LAST,FIRST) P #WITH AREA CODE <br /> IG NAME IV,FIRST) PHONE#WITH AREA CODE NIGHT NAME(LAST,FIRST) #WITH AREA CODE <br /> U <br /> S IA 14 ILA <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST 6E COMPLETED) <br /> NAMCARE OF/AD RESS INFORMATION <br /> MAILING or TREE DDRESS j ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �� Q�J /, / CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (�✓( , V - 4�1� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CI NAME STATE ZIP CODE PHONE# ITH APIEA CC+O(DDE�,'. <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME S Z q CARE OF ADDRESS INFORMATION <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 Ad z /111 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. W11. 0111.❑ <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 /> [PERMITNUMISER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> FT3 DOIt 3 HE Udo <br /> AGENCY FACILITY ID# AP BY NA E PHONE#WITH AREA CODE <br /> PERMIT A))PPR rV,AL DAJ PERMIT EXPIRATION DATE <br /> / G// l CE`fNSUS TRA T/# SUPERV OR-DISTRICT CODE BUSINESS PLAN FILED DATEFILEDGi's -YC/ 7, YES NOPERMIT AMOUNT SURCHARQ AMOUNT FEE CODE RECEIPT# BY: f If <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 0 Y. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />