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Aa # :2�?3 _e160_01 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROLARD <br /> FORM `A': . <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> s � ffiT <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - o <br /> DO- - COMPLETE THIS FORMA FOR EACH F CILITY/SITE <br /> +' I3 RENEWAL PERMIT <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE � I <br /> ONE ITEM ❑g INTERIM PERM(T ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> 00 i <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C <br /> N } <br /> I FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS /� �} NEAREST CROSS STREET ✓ ❑ PAMNRSNIP Cl STATE-ti00 I <br /> I-+ - �(i��T, 5//�f OORPGRATI ❑ =k-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ iNDmwk ❑ CtxMry-AGENC! <br /> CITY NAME STATE ZIP CODE SITE PHONE It;WITH AREA CODE <br /> / cA 5370 <br /> TYPE OF NESS: ❑p DgMBUTOR ❑4 PROCESSOR ✓Box 4 INDIAN EPA ID # #of TANK'e <br /> 1 GAS STATION 3 FARM g OTHER RESERVATION or <br /> ❑ ❑ TRUST LANDS ❑ AT THIS SITE <br /> r <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: ME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME;(LAST,FIRST) PHONE#WITH AREA CODE <br /> eelaze PZ 3� I <br /> r <br /> NIGHTS: NAME(LAST,FKRSTf PHONE#WITH AREA CODE NIGHTS:. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br />{ NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> ��'/�n //{J� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r s 1i Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE -PHONE#,WITH AREA CODE - <br /> III. TANK OWNiR INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STRE ADDRESS - ✓Box {ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C9 PORATiON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDWIDUAL ❑ COUNTY-AGENCY k <br /> CITY NAME STATE ZIP CODE I P ONE It,WITH AREA CODE <br /> CW_ X _ 710 <br /> IV. LEGAL NOTIFICATIO AND BILLING ADDRESS <br /> CHECK ONE{11 SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ III fir, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. � <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> r <br /> LOCAL AGENCY USE ONLY <br /> ENIER <br /> 931 <br /> JURISDICTION# AGENCY# FACILITY IID# #of TANKS at SITE <br /> 1(-,910 / 1319 l/ Q <br /> IO <br /> ENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> s� <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO _LtlPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 8Y: <br /> o ]� <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 ON J <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br /> I <br />