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.STATE ,OF CALIFORNIA WATER RESOURCES CONTROL�'OARD.- �z <br /> FORM `A': _ Am <br /> UNDERGROUND STORAGE TANK PROGRAM n <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE " <br /> MARK ONLY ❑I NEW PERMIT. ❑ 3 RENEWAL PERMIT S.CHANGE OF INFORMATION 7 PERMAN NTLY CLOSED SITE F <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9� <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 1 <br /> FACILITY/SITE NAME. CARE OF ADDRESS INFORMATION <br /> e 0 S� Cr Ie N <br /> ADDRESQ, r NEAREST CROSS STREET <br /> .R ✓� V D0Ers D STATE AG-ETXY <br /> pnncEDEEOEuACENc� M; W"l) INDNIM cuTYa <br /> CITY NAME - STATE ZIP CODE RE PHONE#.WITH AREA CODE Cn <br /> c CA09 9y5�- 87/S <br /> - TYPE OF BUSINESS. ',❑2 DISTRIBUTOR ❑ /PROCESSOR ✓BOX 11 INDIAN EPA IDnIT y..' <br /> IT of TNK's <br /> E] I GAS STATION [D3 FARM r OTHER TRUSTVLANDS ATION OI El /✓ D/L e_ AT HAS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY), EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST). PHONE IT WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> DoYv i 1{ n - -` 6;101)19 (179715 <br /> NIGHTS: NAME(LAST.FIRST)+ _ - . '.PHONE It WITH AREA CODE NIGHTS;:NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 5'Q 1'YL oL <br /> 1 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) ! <br /> NAMET.� .� �� ..,,//.� CARE OF ADDRESS INFORMATION <br /> 4 /Yli ' <br /> MAILING GI REET ADDRS ✓Sox to indicate TNERSHIP D STATE-AGENCY <br /> S ❑ CORPORATION ❑ OCAL-AGENCY D FEDERAL-AGENCY <br /> U tio <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - - STATE ZIP CODE PHONE#,WITH AREA CODE <br /> c.r4 a o ao 4��-87/s <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> -OaVI f2 w h°LY' <br /> MAILING a,STREETADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> _ CITY NAME STATE 21P 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 /> APPLICANT'$NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION If AGENCYNE - FACILITY ID N - .V of TANKS at SITE <br /> CUR RENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAENCOOE CENSUS TRACT I SUPERVISOR-DISTRICT CODE, BUSINESS PLAN FILED NG ❑ DA E FILED <br /> CHECK# 9ERMIT AMOUNT SURCHARGE AMOUNT FEE CODE - RECEIPT# Y:o(/ <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 INFORMATI0 <br /> FORM A(3-2-88) <br /> 1 <br /> `.- DATA PROCESSING COPY <br />