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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM =gym <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . <br /> COMPLETE THIS FORM FOR EACH FA Y/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ll<CHANGE OF INFORMATION ❑ 7 PERM Y CLOSED SITE P4 <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G7"1 <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAMCARE OF ADDRESS INFORMATION <br /> xRNd e, 1p <br /> ADDRESS NEAREST CF)OySS STREET ✓DA 10 imale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> R.A / —rL. ❑ CORPORATION Cl LOCAL AGENCY Cl FEDERAL AGENCY <br /> �Pye, ST ❑ INUNIDUAL ❑ COUNTI AGENCf <br /> CITY NAME aT <br /> STATE <br /> TIP CODE���� �� SIT DNF.=,WITH AREA CODE <br /> TYPE OF BUSINESS 2 DISTRIBUTORE] 4 SS I/Box if INDIAN EPA ID ft #of TANK'/ <br /> RESE <br /> F—] 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSTYLANDS o 11AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. AME L&Kd(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 6S' 1 qle o� Z,B f-�� <br /> up <br /> NIGHTS. NAME(IAST,FIRS ) PHONETO 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 /> � n I <br /> MAILING or STREET ADDRESS vVV ✓Box tolndicate Ll PARTNERSHIP 11STATE-AGENCY <br /> CORPORATION Cl LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> c.Sl/>7Mf Gt S <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. pf 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY APPROVED BY NAME PHONE#WITH AREA CODE <br /> �� Gi3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION <br /> CODE CENSUS��JJTRACT k SUPERVISOR-DIST CT CODE BUSINESS PLAN FILED DATE FILED <br /> T / /"3 ka ? Z YES [:] NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At BY:�� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST"'QR MORE TANK PERMIT FORM 'B'APPLICATION(S), U11I THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 441) FORM A(3-2-88) �- <br /> `� DATA PROCESSING COPY <br />