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STATE OF CALIFORNIS WATER RESOURCES CONTROOSOARD "" f <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7 PERMAN LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> P O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> MFi& ?7v ry <br /> ADDRESSNEAREST GROSS STREET x 1 mtli[ale ❑ PARTNERSHIP D STATEAGENCY (� <br /> N�✓V nnn v'G��/,/a CORPYRATION ElLOCAL AGENCY ElFEDERAL AGENCY N <br /> i INDIVIDUAL ❑ COUNTY AGENCY <br /> CITU NAME / STAT21� w 6 SITE PH Nom,WITH AREA <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax it INDIAN EPA ID # hjV/f #o1 TANK's U <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: AME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ld Merz, 00 -9� -2011 o 100 At za - 6Z�i re <br /> NIGHTS: NAME(IAST,F ST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAS IRST) PHONE#WITH AREA CODE <br /> l <br /> eels 70 3 12 <br /> II. PROPERTY OW ER INFORMATION & ADDRESS - (MUST BE COM LETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MEll <br /> MAILING or STREET ADDRESSox to indicate D PARTNERSHIP D STATEAGENCY, <br /> e CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> (/e D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> S-7,0 lL 0 5W 6i ZpLJ� U <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDY I ox to indicate D PARTNERSHIP D STATEAGENCY <br /> CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME D STAT ZIP CODE / PHONE#,WITH AREA C / <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #OI TANKS at SITE <br /> HzWll 101010l <br /> CURRENT LOCA ENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 02/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> FCICE <br /> TION CODE CENBUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a �u YES NO S '3-� <br /> K# PERMIT CUNT SURCHARGE AMOUNT FEE CODE RECEIPT IF 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 <br /> ONLY. <br /> FORM A(3-2-88) . DATA PROCESSING COPY �/ J/� <br />