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P <br /> STATE OF CALIFORN WA y °wf <br /> TER RESOURCES CONTROL ARD <br /> aPr• ..'si <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM M,0 <br /> SITE , INFORMATION and/or PERMIT APPLICATION <br /> fr t1a r <br /> COMPLETE THIS FORM FOR EACH! ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT FT�5 CHANGE OF INFORMATION ❑ 7 PERM TE ` <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE � <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILI / ITE NAME CARE/OFA D ESS INFORMATION <br /> N <br /> ADD SS N RST CROS STREET �✓ ztoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /��/�, t7 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> " 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME it'� ^ � STATE CZIP C ��� SITE PHO E#,WITH `Yd qEQ1 <br /> CO <br /> CA <br /> 6 b <br /> TYPE OF BUSINESS: ❑ <br /> 1 GAS STATION 2 DISTRIBUTOR ROCESSOR ✓Box if INDIAN EPA ID #3 FARM 5 OTHER RESERVATION or % AT THIS SITE <br /> ❑ E:l ❑ /f/ (� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGE CY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> go <br /> 3/4 <br /> NIGHTS: N (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> SIA S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OFA DRESS INFORMATION <br /> 114 <br /> MAILING or STRett ADDRESS x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY162)d . a ld b 1:1 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMN STAIE ZIP CODE PHONE#,WIT ARI, CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) /f <br /> NAME CARE ADDRES FORMATION <br /> bl Yt r <br /> MAILI G o TREET ADDRESS /' IV.-to indicate PARTN RSHIP ❑ ATE-AGENCY <br /> ►./� <br /> M6kA <br /> rw d� /00 CORPORATION LOCAL-AGENCY ❑ EDERAL-AGENCY <br /> (� v""�J I°' Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE# ITH AREA CODE <br /> CA I <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS yL7 <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ll ,,+ lz9VVl <br /> CURRE T LOCAL AGENCY FACILITY ID# APPROVE YZNME PHONE WITH AREA CODE <br /> 17 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILEID <br /> 7j �� YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SDRC ARG AMOUNT FEE CODE RECEIPT# Y: <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />