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STATE OF CALIFORNI%�\ WATER RESOURCES CONTROZ'doARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER TLV CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE - <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> f <br /> M UT W <br /> ADDRESS / yN NEAREST CROSS STREET <br /> McalO ° PA"NOWIP ° SIATE#GENCY <br /> ;DI O I EEN ° EOW ^C <br /> C Ib <br /> CITY NAME Si r STATE ZIP CODE 24V SITE PHONE#,WITH AREA CODE <br /> ON CA s <br /> TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓RESBoz#INDIAN EPA ID # <br /> ❑ If of TANK's <br /> ❑ ❑ TRUSTYIANDS ATION or ❑ AT THIS SITE <br /> I GAS STATION 3 FARM 5 OTHOt <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 /> GN�o5 re Z <br /> /)c al 674060 ; L it:,4 �9- .6 o <br /> NIGHTS: NAME( T.FIRV) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> l✓V/� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME N CARE OF ADDRESS INFORMATION <br /> DiA-mv/,/r) <br /> MAILING or STREET ADDRESS XRW intlicele ° PARTNERSHIP ° STATE-AGENCY <br /> --P CORPORATION ° LOCAL-AGENCY ° FEDERAL-AGENCY <br /> ( O I D I / INDIVIDUAL ° COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> f-^- ,^ Zd _ 6 —boa <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS of io RATIIO ° PARTNERSHIP ° FEDERAL-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ° 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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# JURISDICTION If AGENCY# FACILITY ID It #of TANKS at SITE <br /> = = I ooh 0 oor7 <br /> CURRENT LOCAL AGENCY FACILITY ID 0, APPROVED BY NAME PHONE N WITH AREA CODE <br /> AML)ID W45 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> l 2 Z 4 P� <br /> LOCATION CODE CENSUS TRACT SUPERVISOR.DISTRI CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO ❑ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> LYl <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 />