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STATE OF CALIFORNIA' WATER RESOURCES CONTROCtOARD <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O Z <br /> to <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS �/� ..#�► NEAREST CROSS <br /> ♦STREET ✓aN,twaa Cl PARTNERSHIP rQ STATE AGENCY w <br /> 17G1/' W� c* A�� W" /J1KI�O ❑ CORPORATION 0 LOCAL AGENCY OUAL ❑ WIINTYAGENLI JFEUEMI AGENCY /^ <br /> CITY NAME W. uTE'n��1 Cr"' r{ '1 rSTATEE Zlq E 1 SITE PHONE#,WITH AREA CODE W+ <br /> CA T <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID# #of TANK's /J <br /> t GAS STATION [-] 3 FARM ❑ 5 OTHER TRUSTVLANDS ATIONor ❑ ATTHISSITE .` <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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to inoicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ^�O 30_o ❑ CORPORATION 0 LOCAL-AGENCY ElFEDERAL-AGENCY <br /> CC ��4l..JJ a INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/80.to inoicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> t <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111.❑ <br /> THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> CANT' E(PRINTED&SIGNAUR DATE <br /> tilA�t >J w� a 2. -2,5JG'7 <br /> LOCAL AGE*Y US ONLY I <br /> COUNTY# JURISDICTION# AGENCY N I FACT ITY IDN (0 M of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM( APPROVED BY NAME PHONE N WITACAASA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE - ••- <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: <br /> 11(� <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(3-2-881 //1 <br /> f`�L/fr� •,,� U DATA PROCESSING COPY <br />