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STATE OF CALIFORNIP WATER RESOURCES CO'NTRALOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM - - z <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑I NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED FJ <br /> ONE ITEM 427 SITE❑2 INTERIM PERMIT ❑/AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> GO <br /> 1.FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) CA) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ��. n A NEARESTCROSS STREET ✓Bph'�ryr ❑ IAAR+Ef91P ❑STATE•AGOX,Y <br /> /�`(nJ(`/, 11 COFlPw" [7 LOGI-AGEO 11FE EW-AGENCY <br /> ❑ NGm m ❑ COUIIYACENn <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> ` ,5-f G CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSORITR <br /> ✓6olr N INDIAN EPA ID N <br /> RESERVATION or ,/� �� N of TANK'N <br /> ❑I GAS STATION �j 'J FARM ❑5 OTHER UST LANDS ❑ ���/'V I `�'� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> V ao 5� <br /> NIGHTS NAME(LAST,FIRST) PHONE A ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME N CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE P.WITII AREA CODE <br /> III. TANK OWNER INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rr <br /> MAILING or STREET ADDRESS ✓Box to in;Acale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: I. fy 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N F CI Y ID N I sn N oI TANKS■t SITE <br /> a00o <br /> CURRENT LOCAL AQ C FACILITY ID N 1APPROVED B NA(E ZI PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMITAPPROVALOATE PE IRATIONDATE <br /> LOCATION COoE CENS S TRACT r - SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> YES ❑ NO ❑ <br /> CSiPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> S <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 />