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or-. <br /> STATE OF CALIFORItlbv WATER RESOURCES CONTRa.--JOARD <br /> FORMW:: a. <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ?f6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ea c Sfa,'o­,,L, #4f751 Iv <br /> ADDRESS NEAREST CROSS STREET ✓ to xica`.- ❑ PAti MFWP ❑ STATE-AGENCY <br /> z u (�� L3r O d�� COW MTION ❑ LOCAL-AGM ❑ FEDERAL-AGENCY Cn <br /> t J J ❑ INDMDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP OESITE PHONE#,WITH AREA CODE <br /> `fo c- 1� �,�. cA 5a o Cao �'G 3- 7i <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓8ox N INDIAN EPA ID # <br /> d ❑ ❑ TRUSRESERESETVLANDS ATION or ❑ k of HIS SITE 1 GAS STATION 3 FARM 5 OTHER 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMCARE OF ADDRESS INFORMATION <br /> a C C' <br /> MAILING or STREET ADDRESS x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Tk� rd ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> if q.3a 3 o1620q)5S,;:;L-0-qy <br /> I11. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sarne er <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ 11. ❑ Ill.❑ <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) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = 1 I Ill I Op / 173 Doo - <br /> CURRENT LOCAL AGENCY FACILITY ID* APPROVED BY NAME PHONE*WITH AREA CODE <br /> ,Ng <br /> aeo3'/- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICY CODE BUSINESS PLAN FILED DATE FILED <br /> a3, Z Q YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N OY: <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(3-2-88) <br /> `W\\ DATA PROCESSING COPY J / <br />