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STATE OF CALIFORNIAATER RESOURCES CONTROL <br /> A RD ;5 « Te <br /> FORM `A': �' y. - �'; <br /> UNDERGROUND STORAGE TANK PROGRAM uo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE `�Fo��> <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 BERMAN CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 16 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) __4 <br /> FACILITY/SITE NAME ARE OF ADDRESS INFORMATION 00 <br /> 84t��-z dieF i F zz <br /> ADDRESS /,�, I NEAREST CROSS STREET ✓BGxta- k PAM NUHIENP ❑ FATE AGENCY <br /> 13Y I EL71'F OAATIDN ❑ LDCAbAGENC! ❑ FEDERAL IVIDUAL ❑ COUNTY AGENCY <br /> CITY NAMEI i STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> Il C,l_ cA Cl �V6 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCEWR I ✓BOX if INDIAN EPA ID It <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ #of TANK'e <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE <br /> #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE//#WITH AREA CODE <br /> u/ <br /> NIGHTS: NAME(LAST,FIRS PHONE WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WIT AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CC\\// CARE OF ADDRESS INFORMATION <br /> c.J�E <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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. 11. ❑ 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 It p of TANKS at SITE <br /> EH = = I oolq= av l <br /> CURRENT LOCAL AGENCY Met!p APPROVED BY NAME PHONE If WITH AREA CODE <br /> SIV <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO CODE CENSUS TINACZp SUPERVISOR-DISTRICT CODE BU771 ::i <br /> DATE FILED <br /> FIIILED <br /> 23 <br /> CMECKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ❑ <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 <br />