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STATE OF CALIFORNIA WATER RESOURCES CONTROD0OARD y ` OF r` <br /> ti. A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLYNEW PERMIT 3 RENEWAL PERMIT 5 CHANGEOF INFORMATION E] 7 PERMANENTLY CLOSED SITE I"+ <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE © N <br /> E] <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) N <br /> N <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION <br /> AIM70 <br /> U)at / NEAREST CROSS STREET ✓6wjp0MT[e ❑ PANT AGD ❑ IMEPAGENCI <br /> /(/(,//un��l7'_' C%/lam ❑ DUPOMTIi ❑ LARTNEI f ❑ STATE AGEGBICY <br /> ❑ INNADUAL D COUNTY AGENCI <br /> CITY NAME r STATEZIP CODE SITE PHONE N,WITH AREA CODE <br /> G CA �I O <br /> TYPE OF BUSINESS: � 2DISTRIBUTOfl � 4PROCESSOR EPA ID N <br /> RESERVATION or - Not TANICS <br /> GAS STATION 0 3 FARM 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> Hiqli, 31 _ y15 Y57-7& 67 <br /> NIGHTS: NAME( ,FIIRS,TTI �� p PHONE N WITH AREA CODE NIGHA. VAME(LAST,FI�RST)� PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AL <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> r ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 1 C / ��" 0 INDIVIDUAL D COUNTY-AGENCY <br /> CIN NAME e D C STATS ZIP CODE PHONE <br /> 7WIITH A " E6 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> saTyue <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D 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. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY N FACILITY ID N #of TANKS at SITE <br /> S7 10Oo 13 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> 1 \� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC ON ODE CENSUS TRACT# SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED NO ❑ O� IFILN <br /> C) 3` <br /> CHECK# PERMIT AMOUNT SURC ARGEAM DL <br /> FEECODE RECEIPT# Y: <br /> HIS 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 /> . iRM A(3 2 88) A � l� <br /> DATA PROCESSING COPY <br />