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STATE OF CALIFORNN WATER RESOURCES CONTROARD : °F r,•� <br /> f 5E••'Eu aiK�'•.1'1 <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICA110binT <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE C4 elF0 RNP <br /> MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITEI�NFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NATE' CARE OF ADDRESS INFORMATION <br /> ADDRESS �� NEAREST CROSS STREET -w/Box to indicate El PARTNERSHIP TATE-AGENCY C <br /> I-] CORPORATION 11LOCAL-AGENCYp FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME _r0a. STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �//0!/�/ CA 6 <br /> 9 s�o <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTORji�5 <br /> CESSOR -/Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'S <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br />{4 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> '54 ��� — Z 3 v e Ali IT y BSS. 8'�l <br /> NIGHTS: NAME .ST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IRST) v PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME \).S , <br /> S /° Qn'1114 CARE OF ADDRESS INFORMATION <br /> e /&U A <br /> MAILING or STREET ADD ESS /� ✓Box to indicate ❑ PARTNERSHIP STATE-AGENCY <br /> /"',, � UI,.I� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (�(�i V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME VSTATE ZIP CODE PHONE It,WITH AREA CODE <br /> aMLw 6 s 3 `'1 a 6 <br /> I11. TANK OWNER INFORMATION &ADD ESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> &17 r <br /> MAILING or STR T ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /y ❑ CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> 1 (/ ( 194V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME d �w w /_ STATE ZIP CODEQPH NE#,WITH REA COD, <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. ❑ if. ❑ III. <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 /> [ER <br /> OUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [ �Jjj l �/ - U s <br /> NT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> # 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(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> _,_ro m ,_,•.r nj x ro . ... <br /> DATA PROCESSIN,, .. .G COPY 9v <br />