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STATE OF CALIFORNI0 WATER RESOURCES CONTROOpARD <br /> CORM `A': UNDERGROUND STORAGE TANK PROGRAM e^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEMARK <br /> ONE ITEM ❑ I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S1TE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ` <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) \' <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> F. <br /> �z <br /> ADDRESS IV <br /> 7�AME <br /> EET ✓BarMMYZV ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S. l ❑ OOFMRA ON ❑ LGru Acw Y ❑ EOEPAL-AGN Y <br /> CITY NAME INDTAWAL COUI/IYAGENCI <br /> l-,� IP CODE SITE PHONE It.WITH AREA CODE <br /> 01� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓Box if INDIAN <br /> ❑ ❑ ❑ TRUSTYLANOS TION or ❑ N of TANK'N ' <br /> 1 GAS STATION 3 FARM 5 OTHER AT THIS S <br /> EMERGENCY CONTACT PERSON(PRIMARY) ONTACT PERSON(SECONDARY) \ t <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IRST) <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE,WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate O PARTNERSHIP <br /> 13 CORPORATION ClLOCAL-AGENCY0 STATE-AGENCY <br /> C3 INDIVIDUAL ❑ COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 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. ❑ it. ❑ 111, <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 B JURISDICTION x AGENCY N FACILITY ID Al Bol TANKS mt SITE <br /> 3 � o � <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME <br /> '5 \A \!7 ' S_ PHONE WITH AREA CODE <br /> PERMIT NUMBER VI�J R— PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> YES <br /> NG 0 DA FI <br /> Igg— <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> BY. <br /> THIS FORM MUST BEIACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY./ <br /> / FORMA 13-2-85) S <br />