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STATE OF CALIFORNIA' WATER RESOURCES CONTROL ARD <br /> FORM `A': °- <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE j FACILITY/SITE, INFORMATION and/or PERMIT APP TION <br /> C/ <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I.#ACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> / FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS r� NEAREST CROSS STREET BMW MM 0 PARTNERSHIP ❑ STATEAGENCY <br /> //�� ��,/ ❑ COR'ORATION 0 LOCALAGDO 0 FEDERALAGENCY <br /> V (.�V r �✓ 0 INDIVIDUAL 0 COUn-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA 37! lJL <br /> TYPE OF BUSINESS: DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if PkIAN EPA ID a <br /> ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER RESERVATION GI ❑ Aof TANK'F <br /> AT iH15 SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ST,FIRST) PHONE 0 WITH AREA CODE DAYS. NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(Ltl.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /Q / � i � CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET AD ESS✓,�i ! ✓Box to intlicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE NE B,WITIT AREA QODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 5 (//(//c_ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ II. P7,11. ❑ <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 S JURISDICTION N AGENCY N FACILITY ID N K of TANKS st SITE " <br /> M = = I I I 2A / T <br /> CURRENT LOCAL ADEN FACILITY 1 M APPROVED BY NAME PHONE N WITH AREA CODE <br /> �0 5�7 <br /> PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS 7TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED _ <br /> �4 7 YES NO 1U'S4 <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> Ca/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FOR (3-2-88) ^ 0 • <br /> \C) %C/ <br />