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STATE OF CALIFORNIits' WATER RESOURCES CONTR8t4OARD <br /> r a <br /> c r �, M, <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : Io <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ErI5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE b ' 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF AD ESSINFORMATII rON <br /> J< J G1i14 <br /> ADDRESS �] Jai /��/j NEAREST CROSS STREEJ� Bo.towdovY 0 PARTNERSHIP 0 STATE AGDIGY <br /> 7 / V n ST (J ❑ ?1DMli 0 COUNT/AGENCY El LOCAL AGENCY 0 FEDERI <br /> N <br /> / &t G IRS .. Q'M6VIDUAL <br /> CITY NAME^� I 1 STATE ZIP CODE ITE PHONE ft.WITH AREA CODE <br /> J IPL/.`T't`y CA Ya6-067-2- <br /> TYPE OF BUSINESS Box if INDIAN EPA ID p X of TANK's <br /> [:] / ❑ 5 OTHER 2 DISTRIBUTOR 4 PROCESSOR ✓RESEROF-1VATIN or AT THIS SITE <br /> ❑ I GAS STATION 1❑ FARM ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA`YS� NAME(IAST,FIRST) /Y �r�PHONE#WITH AREA DE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAM ST,FIRST) 1//`f PHONE WITH AREA CODE NIGHHTTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box tc indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> U// •`-ice' <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ IL ❑ 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 R AGENCYN, FACILITY ID N M of TANKS at SITE <br /> = = = I I 1411AIZAa6 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> 221T <br /> PERMIT NUMPERMIT APPROVAL DATE PERMIT EXPIRATION DATELOCATION CCTK SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE FILED <br /> YES ❑ NO ❑ & aCHECK kUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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(3-2-81 <br /> DATA PROCESSING COPY <br />