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STATE OF CALIFOR41 WATER RESOURCES CONTR OARD ✓5 6""� "� <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM t <br /> abo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -' o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °"LIF ORIA' <br /> " <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P LY CLOSED SITE } <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E!l6 TEMPORARY SITE CLOSURE 9 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CD <br /> FACILITY/SITE NAM /7 CARE OF ADDRESS INFORMATION <br /> GD �.l�G CC U <br /> ADDRESS �( NEAREST CROSS STREET xtoindirate El PARTNERSHIP ❑ STATE-AGENCY <br /> (/J) CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G �� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH SREA CODE <br /> JTO70 CA 6 <br /> TYPE of swess: ❑p DISTRIBUTOR ❑4 PROCESSORFRESBIE0RxV'A'TNON <br /> DIAN EPA ID #1 GAS STATION 3 FARM 5 OTHER or AT THIS SITE <br /> ❑ ❑ ST LANDS ❑ <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 /> YI e- <br /> V6E /!l -9r Ste- a 9—IF Y w <br /> NIGHTS: NAME(LAST,FIRST) f PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> �1 ® 30 < 'Lf c CORPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY <br /> (` / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> S U 7,V Gad- I .� <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME N�MLS CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Q r V / rl I ❑ INDIVIDUAL COUNTY AGENCY ION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME �� STATE _ ZIP COD PHONE#,WITH AREA CODE <br /> � <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. ❑ I <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY` <br /> COUNTY# JURISDICTION# AGENCY# #,ACILITY-ID# #of TANKS at SITE <br /> DM I I I I El I I LOio_'�J EMo 01 ,31 <br /> CURRENT LOCAL AGENCY F��ID# APPROVED BY NAME-- PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# S RVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> © 21 W a_ T YES ❑ NO ❑ ��� <br /> CHECK# PERMIT AMOUNT S CHARGE 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 /> DATA PROCESSING COPY <br />