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...-.-...-,���..F�-�-, .,r•r+�^.�er^�asc-,*wa-r�!-qea •.,o.+�.��a�a. iC'T'..r..�'.�° "'.�pr'P'"P"'"'rw�,e[r,,.. <br /> OF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROAARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLIC <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE C9lo R N`P <br /> I MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT Ir <br /> 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ❑ PARTNERSHIP ElSTATE-AGENCYoindicale <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D , L aeltDO ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME _ � � STATE CZIP CODE SITE PHONE k,WITH AR�A�D� <br /> A �O <br /> i <br /> TYPE of BUSINESS: F7 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 1 GAS STATION E] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE31 <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: NAMEAX,FIAT) PHONE#WITH AREA CODE NIGHTS: NAME A ,FIRST) PHONE#WITH AREA CODE <br /> 71 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BEC PLETED) <br /> NAME ©� C011,1 f�Al ,S CARE OF ADDRESS INFORMATION <br /> rel®� Q <br /> MAILING or STREET DDRESS x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �r' CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /}" <br /> CgA4A vO ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP QODE PHONE#,WITH AREA CODE <br /> Ho wsro N I a6:- /- aD— - 6 <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAMEX�� Gp�Vf�n/V�' �57. CARE OF ADDRESS INFORMATION <br /> S M ` <br /> MAILING or STREET ADDRESS to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> ®ak— CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> (� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> n/ D92l - <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> t CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. [—] it. III. ❑ <br />{I 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 /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 � � � , adz paw <br /> CURRENT LOCAL AGENCY/FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPI TION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT TEE 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 ONL <br /> FORMA(3-2-88) DATA PROCESSING COPY <br /> i <br />