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STATE OF CALIFORNIA• WATER RESOURCES CONTRWARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 ENTLY CLOSED S1TE <br /> MARK ONLY ❑ <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> IO <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FAC? /SITE NAME CARE OF Aqi INFORMATION <br /> VIA <br /> ADDRESS_ NEAREST CROSS STREET ✓Ow CORPORATIO ❑ PARTNLOCAL AGENCY Cl SiAi6AGENW <br /> -3 ❑ CORPORATION Cl COUNTY <br /> Mac❑ INDIVIDUAL ❑ CAUNIKAGENW <br /> CITY NAME I ^ , STATE ZIP 92-C/� ITE PH fJE p,WITH AREA CODE <br /> (/iC/,/i�Cy�L CA G/f...JJJ 33 f g <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 P OCESSOR ✓Bax it INDIAN EPA ID a <br /> RESERVATION or #T TIS SI <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER13ENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME T,FIRST) P NE#WITH AREA CODE DAYS./IA SE(LAST,FIRST) PHO WITH AREA CODE <br /> Jbs-7 <br /> NIG S: NAME FI ST) PHONE a WITH AREA CODE NIGH S: rypME(LAST,FIRST) PH p ITH AREA CODE <br /> 36 — 3 e 9 /yAl <br /> II. PROPERT NER FORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMF. ".I, M CARE 0 D ESS INFORMATION <br /> MING or Sig& ADDRESS -/Ethto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S ❑ CORPORATION ❑ LOCAL-AGENCY DERAL- ENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CI NAME STgTE ZIPCO , <br /> E PHONE �7 AREA CODE D� <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) 6 <br /> NAME CARED ESS INFORMATION <br /> 11MAILING rSTR ETADDRESS ✓B xto indicate 11 PARTNERSHIP 11STATE-AGENCY <br /> T/)D 13 11 <br /> ❑ LOCAL-AGENCY DER -AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST ZIP CODE PHONI AREA CODE <br /> SIM 6 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS S <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. erl 111.❑ <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 #of TANKS at SITE <br /> bG l & 1y I 10UB I ) <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Gm9Am h33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODECENSUS TRACT# SUPERVI -DISTRICT CODE BUSINESS PLAN FILED DAYE ED u/� <br /> O -Z, Z3 YES NO S ! t — <br /> CHECK a 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($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \ FORM A(3-288) • 15 <br /> �Xj DATA PROCESSING COPY <br /> V <br />