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y�PwO F. <br /> STATE OF CALIFORNI0 WATER RESOURCES CONTRAOARD Eu EKgf•T� q <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> COMPLETE THIS FORM FOR EACH F#ClLITY/SITE cq"FaR <br /> F <br /> ARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> f <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Ir-11 00 <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY �..` <br /> �7 y ❑�C 1B�OIA ION ❑ LOCAL-AGENCY [_1 FEDERAL-AGENCY <br /> 9-INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME � STATCA ZIP COD La ZIP <br /> NE#,WITH AREA CODE <br /> F�l <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> El ❑3 FARM 5 OTHER RESERATION <br /> TRUST LANDS or ❑ AT THIS SITE <br />! GAS STATION <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> 4pl� d L✓ <br /> NIGHTS: NAME(LAST,FIRST) /w 1PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> T)) y PHONE#WITH AREA CODE <br /> t> IW �`J— <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ��L_ to <br /> Li— <br /> MAILI or STREET ADDRESS �✓Bo to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2:2 ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE tel{ ZIP CO/DE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) :, <br /> NAME CARE OF ADDRESS INFORMATION 1 <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 ___fZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 0 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOH LEGAL NOTIFICATION AND BILLING: I. ❑ if. � III.❑ <br /> THIS FORM HAS BEEN CO PLrI:. UNDER P NALT1' PE UF?t AND TO THE,PESr,.lgk,f&NOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANZNA (PRINT5,pe&SIGN4TUR ;-. .- V DATE/ I <br /> i <br /> LOCAL AGENCY USR© Y �✓ ?� .r ` <br /> COUNTY# JURISDIE <br /> ` AGENCY ffy., FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ' APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER tPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE' CENSUSTRASUPERVISORANSTFRICT'CODE BUSINESS PLAN FILED DATE FILED <br /> 3" —l`� 1 YES NO CHECK# PERMIT AMOSURCHARGE 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br /> .i <br />