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STATE OF CALIFORNIA WATER RESOURCES <br /> CONTROL`�UARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r b. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE' " 'FOR-P <br /> FR <br /> ARK ONLY ❑e2INTERIM <br /> WPERMIT El3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E] 7 PER Y LOSED SITE <br /> ONE ITEM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q Z <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> R oIV <br /> ADDRESS ,) .,` - NEA RES CROSS jRE T ✓Box t- to ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY co <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE Z CODE TE PHON #,WITH AREA C9° <br /> CA _j 1 22C <br /> ,? ?, 7 �! <br /> TYPE OF BUSINESS: ❑ 2 DISTRI OR ❑4 PROCESSOR [RE,,SBE0RxViAfT,INDIAN EPA ID # #of TANK's <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHER SLANDS ON or ❑ AT THIS SITE a <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIR T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /� V'-' CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓aowlI55ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE# WITHAREA CODE <br /> 032 lob —6 7f/ <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME � � 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 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. D11111, <br /> ❑ <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 <br /> atat)SITE <br /> [ME I I I I L Liu- I / lj-/ _& <br /> lo 1/ I v V V <br /> CURRENAGENCY FACT ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE /�+G� PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (� <br /> 4p3 047-(oD YES NO <br /> CHECK# PERMIT 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 /> 4 <br />