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FORM 'A': <br /> FACILITY/SITE, (LOCATION) INFORMATION and/or PERMIT APPLICATION <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> COMPLETE A SEPARATE FORMA, FOR EACH UNIQUE FACILITY/SITE-(LOCATION) <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 ENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT 4 AAMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> (LOCATION OF TANKS) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I&AMfS� #lo E <br /> ADO9E55 NEAREST GROSS STREET <br /> A7 STATE ZIP CODE SITE PHONE x,WITH AREA CODE <br /> C TYNAME <br /> 6422� CA - <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR EPA IDs s of TANK*s alar SITE <br /> ❑3 FARM TANK ❑ 4 PROCESSOR ❑ 5 OTHER J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - <br /> DAYS NAME LUST,FIRST) PHONE s WITH AREA CCDE DAYS. NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS NAME(LAST.FIRST) PHONE A W�AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> 'me,e. -S - <br /> IL TANK OWNER INFORMATION & ADDRESS — (COMPLETE ONLY IF DIFFERENT FROM ABOVE) <br /> NAME CARE OF ADDRESS INFORMA N <br /> /,Z e <br /> MAILING or STREET ADDRESS <br /> LSO.# <br /> STATE J 21P C00"c PHONE s,WITH AREA CODE <br /> CI NAME <br /> `w, <br /> III. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORM ION <br /> MAILING or STREET ADDRES <br /> CITY NAME STATE 21P CODE PHONE x,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. ❑ IL ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEOGE,IS TRUE AND CORRECT <br /> APPLI NT'SNAME(PRINTED SIGNATURE) �W /'RrG ZjQ DATE <br /> LOCAL AGENCY USIf ONLY <br /> COUNTY N JURISDIC i ION N - A ENCY B - FACILITY ID F B of TANKS d SITE <br /> -- � <br /> CURRENT LOCAL AGENCY IDI <br /> CONTACT PERSON PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE <br /> LOCATION CODE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN DATE FILED <br /> YES NO <br /> CHECKS AMOUNT FEE CODE RECEIPT) BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE FORM B'S, TANK PERMIT FORMS',UNLESS THIS IS A CHANGE OF SfTE INFORMATION ONLY. <br /> FORM A(1.88) <br />