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STATE OF CALIFORNIA!' WATER RESOURCES CONTROL-000ARD <br /> FORM 'A': a � <br /> UNDERGROUND STORAGE TANK PROGRAM m" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION; �' ,n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLYCLOSEDSITE I"+' <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE 5 -d <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) � <br /> FACILITY/SITE ME CARE OF ADDRESS INFORMATION I <br /> i nC,(ja _r- TILLck i Si n CJ os.An <br /> ADDRESS NEAREST CROSS STREET ✓Bm NibUV ❑ PM7NEIGIP ❑ STATE AGENCY <br /> 31 U-)• L i n v e, ❑ CG PoR TM N LDCAL AG N ❑ mEMt9GEND <br /> ❑ IO ❑ CGUNTYAGFND <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA COD <br /> CACIS'J1 20 S7 <br /> TYPE OF BUSINESS: ❑2 DI DR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID It <br /> ❑ 1 GAS STATION ❑3 FARM �SOTHER TRUSTYLANDS ATION or ❑ ^—_ AT THIS SITE O� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S57 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to intlicale ❑ 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 /> Ill. TANK 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 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. Efl- II. ❑ Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION at AGENCY# FACILITY ID N R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID If Si n C L 3-1 APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION DOME I CENSUS TRACT ItHUPERVISOR^-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a d� YES ❑ NO — .�� <br /> CNECK# PERMITAMOUNT SURCHARGE AMOUNT ECODE 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY '1WI4s" <br /> r <br />