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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD <br /> W: <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �oz <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ? � '` r , 10 <br /> P , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE a) <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Cp <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST GROSS STREET ✓Six i <br /> CORPORATIO 0 LOCAL AGEN 0 FEDEMLGENEY <br /> ❑ COAPOAATION ❑ LOCAL-AGENCY ❑ FEOEAAL-AGENIX <br /> R 0 INOIVIOUAL 0 COUNiKAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA g52-os Czc�l -o <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Bax A INDIAN EPA ID # #of TANK's �7 <br /> RESERVATION or1:1AT THIS SITE L <br /> ❑ 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRUST 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 /> 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 /> NAMECARE OF ADDRESS INFORMATION <br /> f1 C S <br /> _T' Ift <br /> MAILING or STREET ADDRESS -/Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> **CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> 41p2l �15� �k1-5511 <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5l�tMl R P �wN09- <br /> MAILING or STREET ADDRESS ✓Bax ro i ATe 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ <br /> CORPORATION 0 LOCALAGENCYOFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# ACILITY ID# If of TANKS at SITE <br /> q a- L') z <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY PHONE#WITH AREA CODE <br /> C0L_ort <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRO SUPERVISOR-DIS RICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 Z YES NO Z/t/-/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AM NT FEE CODE RECEIPT# BY: <br /> ii <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 0 <br /> FORM A(3-2-88) 06 <br /> DATA PROCESSING COPY <br />