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,Fy <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROIL90ARD s<^` <br /> 4 ,A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 1� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK ONLY JJJ ❑ I N PERMIT ❑ 3 RENEWALPERMIT �� ...AKGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE X IUy y <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) ° <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> k cncm4 G <br /> ADDRESS NEAREST CROSS STRE ✓BwwirdY 0 PWNEFSHP ❑ STATE AGENCY N <br /> r_I` i 0` CORPORATION 0 LOCAL-AGENCY 0 FEGERALAGENCY <br /> Oq , ❑ INDIVIDUAL 0 WUNIYAGDO ,y� b <br /> CIT'NAME STATE ZIP CODE SITE PHONE�I�AFA ar6`Y 7 4yb <br /> 4A) CA 3 - <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX if INDIAN EPA ID # <br /> It of TANK'# <br /> F7 GAS STATION ❑ 3FARM ❑ 5OTHER TRUST LANDS ATION Or ❑ 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#WITH AREA CODE <br /> X A -3 (,5 GcOv , 0205) 3744 111 <br /> - <br /> NIGHTS: NAME(LAST,FIRST) AdHONE#WITH AREA CODE NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME "' CARE OF ADDRESS INFORMATION <br /> d d Ga:H-o G <br /> MAILING or STREET AnDRESS ✓BOX to i,dicale MPARTNERS 0 STATE-AGENCY <br /> 3� 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ <br /> 13 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIT'NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> r. Q}-. <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sftr L r <br /> MAILING or STREET ADDRESS ✓BOX to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION 0 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 /> APPLIC NT'SNAME(PRINTE &SIGNATURE) DATE <br /> 1 1 8- / & - 88 <br /> LOCAL AGENCY USE NLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> EE I oa I I 19 1 8" 3 1 od 1 ox <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 9 - --gv <br /> PERMIT NUMBER PERMIT APPROVAL DATE �/J PERMIT EXPIRATIO ATE <br /> /; 00 <br /> LOCATION CODE CENSUSTRACT# Su ERVISOA-DISTRICT(CODE BUSINESS PLAN FILED DATE FILED <br /> YES [:] NO Q- <br /> CHECK# 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 A(3-2-8B) \\J <br /> DATA PROCESSING COPY <br />