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7 <br /> STATE OF CALIFORNIx WATER RESOURCES CONTRO`'CBOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 7- <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE lei" <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWALPERMIT fv 5 CHANGE OF INFORMATION ❑ 7 P OSEDSITE PV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5� W <br /> J <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> IZWFL 7y'k /bY Mike C M(07, <br /> ADDRESS NEAREST CROSS STREET ✓8AWrdittte 0 PABINERSHIP 0 STATE AGENCY <br /> 0 COW04TION 0 LOCAL-AGENLY 0 FEDERAL AGENCY <br /> rcyrti.v 0 INOMOOAI ❑ C0iAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> oc cfvnl CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓F it INDIAN EPA ID aRESE #oI TANK'e <br /> ❑ 1 GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ 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 ft WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> PA,,k O siacp)-i Jo),N u C4, <br /> MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> • <br /> lO 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> oc oN C4 1 2590 / 1 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Same 0.S <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 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 WNICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. III. ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> 6 6 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> R«� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> DE CENSUSTRACT# SUP ISOR-DIST T COD BUSINESS PLAN FILED DATE FILED <br /> qq Z .$6 3 25 YES ❑ NO ❑PERMIT AMOUNT RCHARGE T FEE CODE 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 ^y <br />