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STATE OF CALIFORNIS WATER RESOURCES CONTROGOARD / <br /> Ill � <br /> FORM `A': /UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 195 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �ZJ 1l <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 <br /> W <br /> FACILI /SITE NAM '. / CARE OF ADDRESS INFORMATION <br /> Vlk N WR <br /> ADDRESS NEAREST CROSS STREET ✓BNIOr6UR Cl PMTN9&IP 0 STATE AGDO <br /> 2cr ti. r v� o INUYIORAALDN 0 CW AGEICl LOCAL AGENd C FEUX AGBIO <br /> CIN NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> -tom art CA 2o5g -.q6 - <br /> 3o5-TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ PROCESSOR ✓Box it INDIAN EPA 10 4 <br /> RESERVATION or N of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHEA TRUST LANDS ❑ AT THIS SITE f <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 20 <br /> NIGHTS. NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> �-- <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> �/allr �N 1✓cr u rN� <br /> MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> !9)C S 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ONE M,WITH AREA CODE <br /> .a PH <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,micate Cl PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRISS 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> d 1 t 17 1 a d I o I :/]- <br /> CURRENT <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> LcS 20 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED j <br /> ,2 C <br /> 3 . O D 32-5-- YES ❑ NO 7 r z/51 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> FORM A(3-2-88) /• <br /> DATA PROCESSING COPY J( <br />