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TATE OF CALIFORNIA WATER RESOURCES CONTROROARD �y~ "�r"•` <br /> S W� <br /> FORM `A': am <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�$FORN P <br /> MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT ED15'CHANGE OF INFORMATION ❑7 PERMANEALTIY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE `* <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY ITE AME CARE OF ADDRESS INFORMATION <br /> ADDRESS / NEAREST CROSS STRE ✓ nd ale ❑ PARTNENSNIP ❑ STATE-AGENCY <br /> Rd CORPORATION ❑ LOCAL-AGENCY ❑ R:DERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE V ZIP ODE( � ONE AREA C <br /> CA ! A&O36o _j -6-S <br /> TYPE OF SINESS: 2 DISTRIBUTOR4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ RESERVATION or #of TANK't <br /> E13/1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME tLAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> X09 3��-3�.� <br /> NIGHTS: NAME(LAST,F ST) PHO #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY 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 /> III. TANK OWNER INFORMATION &ADDRE - (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 FO OTN LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AP TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> M I I 1 -1 D I I lob 1 ) 11 HO Klolol_,il <br /> CURRENT LOCAL AG NCY FACILITY ID k �� APPROVED BY NAME PHONE k WITH AREA CODE <br /> jj 4 <br /> PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C !!Cyf1� 8UPERV R-WWTRICZCODE BUSINESS PLAN OFILED NO ❑ D FILE I <br /> CHE k PERMIT AMOUNT J�✓� SURCHARGE AMOUNT/l FEE CODE RECEIPT k BY: /�+ <br /> JIS 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 /> FO A(3-2-88) 0 0 <br />