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Ir.Twr� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL <br /> FORM 'A': a " : <br /> UNDERGROUND STORAGE TANK PROGRAM = " ie <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /7 COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERMANFN LY CLOSED SITE �1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE If •� <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Gw loi,d[ale ❑ PARTNERSHIP ❑ $iATFAGENCY <br /> To ❑ CgflPoAATION ❑ LOGL AGENCY ❑ FEDEflAL AGENLY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> V i C ICA <br /> (aoR W � <br /> TYPE OF BUSINESS'. Li2 DI IBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID It <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTYLANDSATION G ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) l D PHONE It H AREA CODE DAYS NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) A PHONE3p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> S cep_ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or SiREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 11,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> !V& Sr <br /> MAILING.1 S EET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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: I. II. ❑ 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# If of TANKS BI SITE <br /> 0ON � �2 Q <br /> CURRENT LOCAL AGENCY FACILITY to If APPROVED BY NAME PHONE#WITH AREA CODE <br /> ALLk2l'9Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI C DE CEN US TRACT#7 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE IED <br /> 31 a VES NO 6 T/� <br /> CMECNM PERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPT I! BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11ORE TANK PERMIT FORM 'B'APPLICATION(S), UNLEWIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) 0 <br /> DATA PROCESSING COPY <br />