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f <br /> STATE OF CALIFORNIA '-' WATER RESOURCES CONTROL Bu�RD <br /> a_ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C/ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-] 1 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 153 <br /> Imo' <br /> 1.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECACAR81�7j <br /> ESS INFORMATIOIy 1 <br /> y M !/ —/ <br /> ADD R S NEAREST CROSS STREET ✓Box W e ❑ PARTNERSHIP Cl STATE-AGENCY N <br /> RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY �^+ <br /> '.D DIVIDUAL ❑ COUNTY-AGENCY <br /> _. CITY NAME STATE ZIP CODE SIT HONE#,WITH AREA CODE <br /> CA �ZDS� /1 w <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 P 0CESSOR ✓RESBox if INDIAN EPA ID # N of TANWs <br /> 3 FARM❑ 5 OTHER TRUSTvLANDS ATION or 1:1AT THIS S <br /> L] f GAS STATION ITE <br /> V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) I <br /> DAYS: NAME(LAST,FIRST) PH E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Z� 3cs <br /> NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHT$_ NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> I <br /> NAME CARE OF ADDRESS INFORMATION <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 /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ' CARE OF AD KESS INFORMATION <br /> W 4 L 1 rTrb /1•� rr�- I <br /> MAILING or STREET g-MlADDRESS ✓Box to indicate ❑ PARTNERSHIP Q STATE-AGENCY I <br /> N ❑ C RATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE#,WITH AREA CODE <br /> -T_2�m.11 I C_#4 <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 /> EPEBE <br /> JURISDICTION S AGENCY N FACILITY ID N N of TANKS at SITE <br /> ENCY FACILITY ID N APP VED BY NAM PHONE N WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT N SUPER SOR-DI ICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z3 � YES k0 <br /> PERMIT AMOUNT SURCHARC AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) I <br /> DATA PROCESSING COPY '�/� <br />