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STATE OF CALIFORNIP WATER RESOURCES CONTRWARD <br /> W: <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE �I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> l�-� COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Eff5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 9 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> TP I NKLED yS ACM�)cu4r WAW <br /> ADDRESS /7 '/ NEAREST CROSS STREET ✓Gm 10 ncol? ❑ PMTNgWP ❑ STATE-AGDIC/ <br /> 3/9µ/f S. Hw 33 ❑ 0WORATION ❑ LOCAL-AGENp ❑ FOVAL-AGOV <br /> ❑ INDYIDUAL ❑ WJJTY-AGENCY <br /> CITY NAME �N�� STATE ZIP ` SITE PHONE p,WITH AREA CODE <br /> CA ✓ <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑#PROCESSORif INDIAN EPA ID N N of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM f/ 5 OTHER RESERVATION or TRUST LANDS ElAT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IN Ic 09 835 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> [7Wg c- Ca0 <br /> 9 R23 ✓oPf <br /> Il. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 50PY7C aS 6LhOI/e- <br /> MAILING or STREET ADDRESS ✓Roz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5' me a5 c2bvvp_ <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-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. IT�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 k JURISDICTION M AGENCY# FACILITY ID N If of TANKS at SITE <br /> 3 � = [m 0o � i l © v 0 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE a WITN AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Jn _Q_ YES NO E] <br /> CH <br /> ECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: Y, <br /> THIS FORM MUSj9 ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. _ <br /> FORM A(3-2-RB) v� <br />