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� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROLSARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE `4ttroaAP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERM? ❑ 6 TEMPORARY SITE CLOSURE � TV <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 00 <br /> FACT ITY/SITE NAME CWim-- CARE OF ADDRESS INFORMATION <br /> samd <br /> ADDRESS rCA <br /> REST CROSS STREET _ - ✓R ;rale PARTNERSHIP ❑ STATE-AGENCY <br /> piPRPORATION Cl LOCAL-AGENCY ❑ FEDFRAL-AGENCY <br /> LA I NDIVIDUAL ❑ COUNTY-AGENCI' <br /> CITY NAME - TE Zd CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑4 PROCESSOR ✓Box if INDATION IAN EPA ID # <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSRESET LANDS®r ❑ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WPTH AHEA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> 7— <br /> I <br /> A E D CARE OF ADDRESS INFORMATION <br /> - <br /> MAILING or STREET ADDRESS ��✓B�--SSoo indicate 1:1PARTNERSHIP El STATE-AGENCY <br /> '� Q IkI�CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> K70 k It � -'[S <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME /'� CARE OF DRESS INFORMATION <br /> MAILING or STREET ADDRESS ��✓BB�-to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C / /7�7l� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> TF"UV ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> f�`' I C <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: 1. ❑ 11. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRWTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS et SITE <br /> f1 <br /> C <br /> URRENT AQENC ACILIV(I®N APPROVED BY NAME PHONE N WITH AREA CODE <br /> IT NUMBER PERMIT APPROVAL'DATE PERMIT EXPIRATION DATE <br /> TI�O(N^�CODE CENSUS TRACCTT9 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILO - Z5� � YES ❑ NO ❑ � Ip 7K A PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> I- <br /> T411 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(3-2-88) <br /> DATA PROCESSING COPY <br />