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TI <br /> STATE OF CALIFORNI11 WATER RESOURCES CONTRAIDARD <br /> FORM `A': pss; <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE go <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMAN NTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ~ <br /> ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) —4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 00 <br /> ADDRESS NEAVEST CRSS S�TRET <br /> to igrate13 PARTNERSHIP11 AGENCYSTATE 11 CORP TION 11 LOCAL AGENCY 13 FEDERAL <br /> AGENCY <br /> CITY NAME INDIVIDUAL 0 COUNTY AGENCY <br /> STATE ZIP CODE SITE PHONE X.WITH ARCL <br /> o�� 7aa CA 95'2 / ZO <br /> O <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID X <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLATION NOS or ❑ Xof TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST( PHONE X WITH AREA CODE DAYS'. NAME(LAST,FIRST) <br /> � , PHONEp WITH AREA CODE <br /> kle <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE N GHTS: NAME( T,FIRST) J <br /> PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S{/VYY�Q <br /> MAILING or STREET ADDRESS if I,to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCV ❑ FEDERAL-AGENCY <br /> CI NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 6p�[ CARE OF ADDRESS INFORMATION <br /> tel/ <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITU NAME <br /> 11 INDIVIDUAL 11COUNTY-AGENCY <br /> 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. ❑ 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 R JURISDICTION X AGENCY X FACILITY ID X X o/TANKS at SITE <br /> 0O 37 EEbO <br /> CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> Fil/Fi� �O/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> 2�J �y/ 7 DATE FILED <br /> 7 3 V l�c� YES NO <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY. I <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 /> r FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />