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STATE OF CALIFORNIA WATER RESOURCES CONTRCOOARD <br /> FORM A. UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONqS I " <br /> l� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) a c <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Ci S S �Q r I.0 S <br /> ADDRESS F �) NEA EST <br /> CROSS STREET <br /> STREET ✓Boe to i0ndicate ❑ PARTNERSHIP ❑ STATE AGENCY N <br /> e r Iq✓ X//r eI I c a �IB�IFOIVIBUALION 0 COUNTY AGENCY FEDERAL '�.• <br /> W <br /> CITU NAME ^� � � STATE ZIPf ODE HE PHONE p.WITH AREA CODE <br /> J CA !�a o oZ a Ca- <br /> TVPEOFBUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box it INDIAN EPA ID a of TANK'sp <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETATION or LANDS ❑ /✓ Q C_ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE OAVS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> aoq �5-ds , C: S Fss aoy y�s� y� <br /> NIGHTS. Ni,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> S CC YM e Sic e <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME Cl "!i CARE OF ADDRESS INFORMATION <br /> �'. a u SS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> 49 <br /> Til9RPORATION 11LOCAL-AGENCY [IFEDERAL-AGENCY <br /> BYINOIVI DUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> _a ao9 5-dIl 5 a <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> .sq vn e r e <br /> MAILING or STREET ADDRESS I/11 <br /> to Intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOGAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. If. ❑ 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# JURISDICTION N AGENCY# FACILITY ID# #of TANKS at SITE <br /> = = G6 13 I 000 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROV D B NA E PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If S PERVISOR-DISTgtCT CODE BUSINESS PLAN FILED ❑ DATE FILED <br /> o(y YES NO 7 CTn/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> r , <br />