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STATE OF CALIFORNIA WATER RESOURCES CONTROL..DARD '"" l" <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM „) <br /> SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'���oa"" <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT <br /> S CHANGE OF INFORMATION ❑ 7 TLYCLOSEDSITE F'a' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> Ca <br /> FACILITY/SITE NAME , CARE OF ADDRESS INFORMATION <br /> FIs k � Gv�F Cvutis <br /> ADDRESS NEAREST CROSS STREET ✓PmtotQW 0 PARTNERSHIP 0 STATE.NGDO <br /> 0 GIRIMNON 0 LOGLAGDO 0 FmBdLL-AGBIG' <br /> O 1ti O N O INGMDUA 0 WUNTYAGOICY <br /> CITY NAMES-7 <br /> I STATE ZIPCQDj,. SITE PHONE#.WITH AREA CODE <br /> h'/I CA (/4/JS <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ J FARM ❑5 OTHER TRUSTYLANDS ATION or ❑ 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 N 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 ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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: L ❑ IL ❑ 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 /> COUNTY M JURISDICTION M AGENCY R FACILITY ID N a of TANKS at SITE <br /> ® = = I I I / G E 101/111 <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA.CODE <br /> VANOU 11 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOF ISTRI CODE BUSINESS PUN FILED ❑ DATE FILED� <br /> AV` 2k� 32 YES ❑ NO <br /> CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: w ,r <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 /> FORMA(3-2-88) (/ <br /> DATA PROCESSING COPY <br />