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STATE OF CALIFORNI; WATER RESOURCES CONTRC /OARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM m" <br /> SITE ' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION $� <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [�]_S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑Z INTERIM PERMIT ❑ b AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> AGGRESS NEAREST CROSS STREET ✓BNbMCM ❑ I'MTND6XIP Cl STATE AGENCY <br /> N. I✓I Q ( ❑ CORADUTION Cl IOOLAGENX Cl FEDEW AGU+LY <br /> 13NDVIDA D WIMAGBN,Y <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> /�Gt n feces CA hof- - G <br /> TYPE OF BUSINESS: ❑p DISTfIfUTOR ❑ 4 PROCESSOR I ✓Boz it INDIAN EPA ID N <br /> ❑ I CJS STATION ❑3 FARA ❑ 5 OTHER TRUER SEVATION LANDS of ❑ #of TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(UST.FIRST) PHONE Y WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING IN STREET ADDRESS ✓Box to iwicale PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /T�UVe <br /> MAILING OI STREET ADDRESS ✓boa loietficale D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENGY <br /> CITY NAME STATE ZIP CODE PHONE N,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. IL ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO 70 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION R AGENCY# FACILITY ID S S of TANKS N SITE <br /> v 1 0 ), I v � l10101010 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> bal-7,4 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Is <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEMAD <br /> V y YES F] NO ❑._ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> Crr� 9�9 a J <br /> s <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 /> WHM A 13-Z M, <br /> y <br />