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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD <br /> FORM `A' UNDERGROUND STORAGE TANK PROGRAM =" o <br /> SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m< to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT —,`CHANGE OF INFORMATION ❑7 PERMANEN Ma <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C) <br /> C7'I <br /> FACILI /SITENAME CA,RE/OF ADDRESS NFORMATION <br /> N <br /> ADDRESS ,y �,� ENCY <br /> NEAREST CROSS STREET ✓8Nbndree 0 PWINEABOP 0 STATE-AGENCY <br /> �� � A+V r+iu/`r ElI,WID CORPORATOR 11 WUNIY0 LOM YAGINCY = <br /> CITY NAIE STATE ZIP CODE SITE PF(ONE k,WITH AREA CO <br /> 0z CA ((��Z Zoiv 36/ S3 <br /> TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4 PROCESSOR I '/Box it INDIAN EPA ID# #of TAN K,3 <br /> RESEASSTATION ❑ 3FARM ❑ 5OTHER TRUSTYLANDSVATIONO' ❑ AT THISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER NCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FI ST) q PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PONE#WITH AREA CODE <br /> Q�Yv 1 C - <br /> GHTS: NAFIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) IfFONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF DDRESS INFORMATION <br /> iIJA <br /> MAILING or BTREET�DORESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> (TR/E U-E�`-// 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> loel ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME ( STATE ZIP CODE PHONE#.WITH AREA CODE <br /> L,4,6I -7-� R <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ❑ 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&SIGNATURE) DATE - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE <br /> avz630 101o0 <br /> CURRENT LOCAL AGENCY FACILITY ID# I APPROVED BYN E PHONE#WITH AREA CODE <br /> 64 ?,- / 6 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT (RATION DATE <br /> LCHECK# <br /> ODE CENSUSTRACT#, SUPERVISOR-DISTRICT CODE BUSINESS PSN FILED NO / GAT�p L�r <br /> Z3 -fib PLr�JT PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY.,- <br /> FORM <br /> NLY.,FORM A(3 2-88) \ <br /> 1 �v \ • DATA PROCESSING COPY <br /> � <br />