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� �OF T. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL 0ARD �!5: E�iiK;'•.ti��A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM `� <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; ; �� <br /> /r- <br /> GCOMPLETE THIS FORM FOR EACH FAC! /SITE <br /> MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT Ej� CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM U 2 INTERIM PERMIT E]4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE Lm <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> II FACILITY/SITE NA .,,, �RE OF' ESS INFORMATION d��` <br /> OX 1;6 <br /> ADDRESS tyt lN' / �/� !J�[�fJ NEAREST CROSS STREET ✓Bortoindicate PARTNERSHIP ❑ STATE-AGENCY <br /> i <br /> 1) \,5 f) , l..i ti 1r�5 •• 1 A A S\LL ` 3 ❑ NDIVIDUALION ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ST TE ZIP CODE SITE PHON WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> wl 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> MERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( ST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> N <br /> NIGHT N I E(LAST, T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING 476A S ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PO <br /> RATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ( VIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST EZIP CODE PHONE#,WITH AREA CODE <br /> I q� <br /> III. TANK OWNER IN ORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME pp j t \ CARE OF ADDRESS INFORMATION <br /> 1�v <br /> MAILING or MEET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ POIDRATION 1:1 LOCAL-AGENCY 13FEDERAL-AGENCY <br /> Lel INDIVUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST ZI CODE PHONE#,WITH AREA CODE <br /> e <br /> IV. LEGAL NOTIFICATIO AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PEN OF PERJURY Alf TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> A CANT'S'NAME(PRINT&SI ATURE) DATE <br /> t � <br /> � % <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I / c _ 0 / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTT## SUPERVISOR-DI TRICT ODE BUSINESS PLAN FILED DATE FILED <br /> Z �3— U v r:—7 YES NO I � fY <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT TFEE CODE RECEIPT# BY: <br /> i <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 ONL . <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY • <br />