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STATE OF CALIFORNIA WATER RESOURCES CONTRO 40ARD <br /> a <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM m1 " <br /> S�T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> 1 F9 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Polar Wot2r nc. <br /> ADDRESS NEAREST CRO SS STREET ✓ oiMicate 0 FN NFASNIP 0 STATE-AGM <br /> N <br /> Da W♦ /i r B i I V SCT(/17 �D S-e- 11INDIIVIOUALION ❑ 0O NryAB D ❑ FEG AI-AGE*N <br /> CITY NAME STATE ZIP CODE I SITE PHONE N,WITH AREA CODE <br /> G `fDYL. Ca 5a o 3 dog X610-�, 7G to <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 P50ESSOR ✓BaxiIINDIAN EPA ID # <br /> ESE❑ 1 GAS STATION ❑ 3 FARM Ele-OTHER TRUS7YLANDS TIONor El r`� 0,V e 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#WITH AREA CODE <br /> Ha ase t <br /> NIGHTS: NAME(LAST, RST) PHONE K WITH AREA CODE NIGHTS:. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> s® m e Pok)'tro5-4o9d <br /> Il. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION � <br /> Q QN �N <br /> MAILINGor STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> V I I D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> GG 5ao/ <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tointlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. X 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 A JURISDICTION R AGENCY# FACILITY ID# It of TANKS at SITE <br /> m 10a � o � q <br /> CURRENT LO AG <br /> dol *ENCY FACILITY IDA APPROVED BY NAME PHONE If AREA COOS <br /> is <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT♦ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 /> FORMA(9-2-88) <br /> \ � DATA PROCESSING COPY S <br />