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STATE OF CALIFORNIA' WATER RESOURCES CONTROLTOARD l <br /> FORM A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT JW5 CHANGE OF INFORMATION ❑ 7 PERMANENTL CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE v <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FAC TE NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> ADDRESS AllROSS STREET �✓ vNiMicaN ❑ PARTNERSHIP ❑ STATEAGENCY Co <br /> .KCOAPOAAiION ❑ LOCAL AGBKY ❑ FEDAAIAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTIAGENCY <br /> CITY NA STATE ZIP ODE SITE PHONE#.WITH AREA CODE <br /> CA 2 I <br /> TYPE OF BUSINESS p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ESEto !ANICS <br /> L] I GAS STATION ❑ 3 FARM �TOTHEfl TRUSTVLANDS ATION or ❑ �V / ' E. AT TNIS SITE 2— <br /> EMERGENCY <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE [NIGHTjp, <br /> AYS: ME(LAST.FIRST) PHONE N WITH AREA CODE <br /> en b -9w_ <br /> 3 _ " <br /> NIGHTS: NAME(LAST, RS PHONE#WITH AREA CODENAME(LAST�FIRS ) PHONE#WITH AREA CODE <br /> o en r <br /> 11. PROPER OWNE INFORMA ION &ADDRESS — (MUST BE COMPLETED) <br /> NAME a CARE OF ADDRESS INFORMATION <br /> MAILING or RE ADD S ✓By xto indicate ElPARTNERSHIP ❑ STATE-AGENCY <br /> 1��CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _2_101 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM STATE elZIP ODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/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.W 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 If If BT TANKS at SITE <br /> M = = 16 ci I / -W OO CJ <br /> CUR�GENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER '5a+• PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT NO SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO DAT FILED <br /> (`� 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 IN RMATION ONLY. <br /> FORMA(3-2-88) J\ <br /> �"' DATA PROCESSING COPY �w <br />