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STATE OF CALIFORNIA' WATER RESOURCES CONTROL ARD 5 '""` <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITEi FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o_�: <br /> / COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY E I NEW PERMIT F-] 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 TLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF AP ESS INFORMATION <br /> w;WI AQI-2-o o411A <br /> ADDRESS NE REST OS$STREET ✓BORPOMT ❑ LOCAL AGENCY <br /> ❑ STATE AGENCY N <br /> Z ///Ij� ❑ a.POPATION ❑ PAWNEGENG E GENC QO <br /> NTYAGENCY <br /> CITU NAM �' STATE ZIP CODE ❑ NDN�`ITE PO CEp.WITHAREA ODE <br /> CA Ya o" TLS`763 <br /> TYPE OF SINESS: � p DISTRIBUTOR ❑4 PROCESSOR ✓Boz R INDIAN EPA ID k k of TANK's <br /> STATION ❑ 3 FARM ❑ 5 OTHEfl TRUSTLANDS <br /> ATION or ❑ AT THIS SITE4. <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA NAME(LAST.FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHO p WITH AREA CODE <br /> 7v7 yam,. <br /> NI HTS: NAMKASTAFRST PHONE k WITH AREA CODE NIGHTS: N ME(LAST,FIRST) P p WITH AREA CODE <br /> C) <br /> - yS A r <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NA l o REOP ADDRESS INFORM ATI I <br /> pAlaux-b (I� Esu ^z <br /> MAILWG ar STREW ADDRESS to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY ME STATE 21P COD ) MONE 4 WITH AREA CODE <br /> CA r z-I (C. <br /> III. TANK OWN _MV0hMATIOPl& ADDRESS - (MUST BE COMPLETED) <br /> NA CARE OF DRESS INFORMATION <br /> MAILI `o5REET ADDRESS / �✓$$ppkx to irdi.al. ❑ PARTNERSHIP 0 STATE-AGENCY <br /> B'CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITU STATE Z CODE HONE WITH AREA CODE <br /> eA <br /> OZ Ai)WITH /L <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: 1. ❑ I. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION k AGENCY k FACILITY ID k B of TANKS at SITE <br /> ® ID 101 1010 10 <br /> CURRENT LOCAL AGENCY FACILITY ID If APP VE BY NAME PHONE k WITH AREA CODE <br /> R zz <br /> PERMIT NUMBER PERMITPPP VAI ATE PERMIT EXPIRATION DATE <br /> 7 L <br /> LOCATION CODE CENSUS TRACT kPERVI 0 --DISTRICT CODE BUSINESS PLAN FILED DAT FIL 6 <br /> '� �O VES NO - 6 d <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Of I 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />