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STATE OF CALIFORNIAP WATER RESOURCES CONTROAARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITEI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER 19TLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE I <br /> ID <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CAREOFAD RESSINFORMATION <br /> YA <br /> N <br /> ADDRESS NEAREST CRO-SS/STREET ✓BOFb udicale ❑ PARTNERSHIP ❑ FATEAGENCY11A ((� <br /> ❑ INGIVIGIIAIIDN [:] ��AG CY 13 FEDERAL <br /> CITY NAME STATCA ZIP CODE O <br /> ❑ ATION ITE PRO E p,W 1H AREODE� <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR M/5 <br /> 4 PROCESSOR ✓Box if INDIAN EPA ID or /} #of TIAANKK's OPjQb <br /> ❑ 1 GASSTATION ❑ 3 FARM u s OTHER TRUSTTYLANDS or F-1 kl <br /> 7Ql AT THIS <br /> SITE G/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE WITH AREA CODE DAYS: N ME(LAST,FIRST) PHONE WITH AREA CODE <br /> - 6 S' y <br /> NIGHTS: NAME(LAST,FIRST HONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHON #WITH AREA CODE <br /> s A S/ s <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ODRESS INFORMATION <br /> S A _L m G a, e A <br /> MAILING o BEET ADDRESS ✓Boz to inGicala ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> N ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> &?INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP C OF PHONE q WITH AREA CODE <br /> r 5 A <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF DRESS INFORMATION <br /> 1 - A A <br /> MAILING or 9TREET ADDRESS ✓86to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> y ❑�2ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �✓ °V B INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME Yr �,. STATE ZIP CODE PHONE ,WITH AREA CODE <br /> S A S S <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. if. ❑ 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# AGENCY# FACILITY ID It At of TANKS at SITE <br /> 3 1 o t I 9 I , Z* 10 Ill <br /> CURRENT LOCAL C/ AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> (--Y,4 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> N CODE CENSUS TRACT# SUPERVI R-DISTRICT CODE BUSINESS PLAN FILED DAT FILELL _ <br /> 23.F6 / YES NO 7i <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 INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> lA#I„J\ DATA PROCESSING COPY <br />