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yl•��V..m�.r OM1 <br /> STATE OF CALIFORNIA* WATER RESOURCES CONTROI&ARD , <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PE MIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ElI NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E]7 PERMA ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT- ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C D <br /> 1. FACILITY/SITE INFORMATION b ADDRESS — (MUST BE COMPLETED) <br /> FAGII ITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> NEARt I'T <br /> ADDRESS NEApEST CROSS STREET ✓Bmrow D N/AIMRSW p FE*MSTATE OCT <br /> AGD <br /> D offiaATION D DA*MA BI u ROFR4 AGDILY <br /> ❑ r ❑ -�,C` <br /> -- STATE ZIP CODE SITE PHONE N,WITH AREA ODE <br /> CI I NAME �.. CA <br /> s 95� �>cci �- 7 _� <br /> 6 ' <br /> EPA ID N <br /> TYPE OF BUSINESS-. ❑2 DISTRIBUTOR ❑ P R I/Box il INDIAN <br /> RESERVATION or ❑ AT THIS SITE <br /> I GAS STATION ❑3 FARM OTHER TRUST LINOS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> -/d / wl�/G� Z� y- S7i -c�b 3S - <br /> lu o> )l <br /> NIGHTS. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> GE', // / c m <<, <br /> MAILING o,STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEFEDERAL <br /> L ENCY <br /> AGENCY <br /> �� /L. D C PORATION D LOCAL-AGENCY D COUNTY AGENCY DFEDERAL-AGENCY <br /> 2� f <br /> STATE ZIP CODE PHONE N.WITH AREA ODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓Box to indicate D PARTNERSHIP D STATE AGENCY <br /> MAILING m STREET ADDRESS <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL DCOUNTY-AGENCY _ <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> GI NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WNICN ABOVE ADDU"SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION Y AGENCY B FACILITY I//D Al S of TANKS at SITE <br /> FTI <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> `X, S <br /> PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-01 ICT CODE BUSINEtB PLAN FILED DATE FILFO <br /> 7 �c T CTI 3 YES E] NO � / Z I <br /> __.. RECEIPT <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE L c Ljy L <br /> ` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'S'ApFALICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 0 <br /> ��IOMM AIJL tltll • � ,�� ` <br />