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STATE OF CALIFORNIPW WATER RESOURCES CONTROL.OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo <br /> u �" <br /> m1� <br /> SOS FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION! ' j o <br /> _;� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �''1j•�R"'� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EiloCEHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS TE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE _4 <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) Q <br /> O <br /> FACI ITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 's /9u <br /> ADORESSI r!� NEAREST CROSS STREET ✓wo rdcme 1:1PmrNmr ❑ STATE-AGee <br /> (7'(' f /W//I ❑ T ❑ LOCAL4CZV ❑ FMk-AGENCY <br /> ❑ cum-Kaci <br /> CITY NAME r4STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA T !?,'5QIQ d0i <br /> qqq/ <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 11 INDIAN EPA 10 # t of TANICs <br /> RESERVATION <br /> ❑ 1 GAS STATION E]3 FARM �OTHER TRUST LA DS or <br /> 1:1AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 REET ADDRESS ✓UWfo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 130'CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D 3& ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> a ab "-6 133 <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STR ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 71 PHONE#,WITH AREA CODE <br /> Id. LEGAL NOTIFICATION 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 PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 3 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION A AGENCY# FACILITY ID ar #of TANKS at SITE <br /> [J�l I I 1 1 El I I 1010 1 / 13 10 61 d <br /> CURRENT LOCAL AGENCY FACIL�IQ# APPROVED BY NAME PHONE#WfTH AREA CODE <br /> G <br /> � S <br /> PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3. U YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> mmmmmm, I E <br /> THIS FORM DUST 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 />