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T� <br /> 'r <br /> STATE OF CALIFORNIA' WATER RESOURCES CONTROCI&ARD , `` Sul r�R <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r = o <br /> 7 COMPLETE THIS FORM FOR EACH FACILITY/SITE "&OF,R",' <br /> c <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANEWILY CLOSED SITE r <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D <br /> fV <br /> I. FACILITY/SITE INFORMATION III ADDRESS— (MUST BE COMPLETED) CD <br /> FACILITYMTE NAME CARE OF ADDRESS INFORMATION <br /> s ;s <br /> ADDRESS NEAREST CROSS ST EET ✓Oft 10ft%M ❑ IMITNERSIMp ❑ STATE-AGEN(Y <br /> tY7 IV• w S-UV+J 8 14D r ❑ CORPORATION ❑ LOCALW.M'Y ElFES 44GDO <br /> 13fNDWW& ❑ CDUNTY-AGENCY <br /> CITY NAME s STATE ZIP CODE SITE PHONE•,WITH AREA CODE <br /> CA D � i <br /> TYPE OF BUSINESS: F72 DISTRIBUTOR 4 PROCESSOR ✓Box ii INDIAN EPA ID Y TAT <br /> TANK i <br /> RESERVATION or <br /> I GAS STATION ❑3 FARM UefHER TRUST LANDS ❑ THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,F RST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �i 07 31- Ifi I <br /> NIGHTS: NAME(LAST.FIRST) V PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Or WITH AREA CODE j <br /> I <br /> 1 <br /> II. PROPERTY OWNER INFORMATION S ADDRESS —(MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> ; <br /> ' awv AcIs7ewH <br /> MAILING or STREET ADIRESS ✓Box to indicate ❑ PARTNERSHIP 13STATE-AGENCY i <br /> ❑ SpMPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY II <br /> Ivivaod. DIVIDUAL ❑ COUNTY-AGENCY i <br /> CITY NAME STATE ZIP C E PH+O�NE N, TH AREA CODE ' <br /> ate*teud a. KCq 31 -4i4G 1 <br /> III. TANK OWNER INFORMATION S ADDRESS— (MUST BE COMPLETED) t <br /> NAMECARE OF ADDRESS INFORMATION <br /> 1 I I iam,, +ogejo # <br /> MAILING or STREET ADDRE ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ^ r- 5�� ZIPODE PHONO,WITH ARFA �D �� k <br /> TATE <br /> IV, LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADW W 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE f <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# AGENCY A FACILITY ID S 8 of TANKS a1 SITE <br /> ] D1113 4 ! D o <br /> CURRENT LOC AD FACILITY 1 APPROVED BY NAME PHONE U YWTH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> { <br /> LOCAQON DE CEN8U8 TRACT• SUPERVISOR-DISTRICT CODE BUSINE$8 PUN FILED NO ❑ DATE�LEU <br /> 'I © 1 Jr <br /> CHECK• PERMIT AMOUNT $URCNARQE AMOUNT FEE CODE RECEIPT i 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 A(3-2-99) <br /> >� DATA PROCESSING COPY <br /> 1 <br />