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STATE OF CALIFORNO WATER RESOURCES CONTRAROARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE O FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS r � o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM Ea 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D`Z� <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/ TE NAME�� �/ CARE OFA DRESS INFORMATION <br /> Z4 kag_6/M1 mi A <br /> ADDRESS_ � ) J / NEAREST CROSS STREET ✓Si rto iMirale ❑ PARTNERSHIP ❑ STATE AGEND <br /> W [t LA. L1✓• ❑�NDMDUPON 11❑ CO NN AGENCY <br /> LAGENY ❑ FEDERAL AGENCi <br /> CITY NAMFj D/ STATE ZIP CODE SITE HONE 4,WITH AREA C0 E <br /> f//_on CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #ESE #OI7ANK's <br /> P 1 GAS STATION [:]3 FARM ❑ 5 OTHER TRUSTY <br /> LANDS ATION o ❑ A AT THIS SITE D� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LRST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 35 -ar6i S?9.01 (* <br /> NIGHTS: NAM (LAST ST) PHONE#WITH AREA CODE NIGHTS: AME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF A DRESS INFORMATION <br /> 6Lw N A <br /> MAILING or tSTIEETDRESS ✓Box to indicate ElPARTNERSHIP ClSTATE-AGENCY <br /> HI I/1 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDER L-AGENCY <br /> G� 13INDIVIDUAL ❑ COUNTY-AGENCY 117 r <br /> CITY NAMP STATE- ZIP CODE PHONE WITH AREA COD <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAU, CARE OF DDRESS INFORMATION <br /> MAILI or STREE DDR S U eoxto'maicate 1:1 PARTNERSHIP ElSTATE-AGENCY <br /> �1 .qp / ❑ NDIVIDUALON 11 COUNTY AGENCY 0 LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CA o aa-F 2 'Z-6113 1 <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. Q it. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 35 o v <br /> CURRENT LOCAL AGENCY FACILITY ID If APP V Y NAME PHONE#WITH AREA CODE <br /> 2 � /0 <br /> PERMIT NUMEV PERMIT APPROV^L DATE PE MIT EX IRATION DATE <br /> �D ,7407 <br /> LOCATION CODE CENSUS TRACT# SU ERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> v_?i .� (-11 YES ❑ NOi 2 <br /> CHECK# PERMIT AMOUNT SURCHARGE IUAOUNT 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 0 <br />