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STATE OF CALIFORN WATER RESOURCES CONTR&OARD �P hEP^ se <br /> FORM `A'• = <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C�!FORN P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S z <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 20 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> O (^viC.e f <br /> ADDRESS NEAREST CROSS STREET ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> G� J U/, ; CORPORATION El LOCAL-AGENCY ElFEDERAL-AGENCY00 <br /> �f ❑ INDIVIDUAL ❑ COUNTY-AGENCY w <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE "J <br /> G CA Caog 547P- <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's Q <br /> ❑ 1 GAS STATION ❑ 3 FARM E�fOTHER TRUST LANDS ❑ n AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> G a r es P. 3a r Sa-vi-f; C��r X78' g7�o <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> a4 zf-7 3 Of a 7 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Go odyea Y, ri d` Ru 6 ber <br /> MAILING or STREVf ADDRESS ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> i Q EI CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> I G / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE It WITH AREA CODE <br /> UK <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a e rl <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <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. II. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 60 ,:R I / I Y- 7 1 . F—n (�7 (5d <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Q <br /> (?-0YES ❑ NO ❑ CJ of 00 ' <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT --l-FEE CODE RECEIPT# 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />