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r <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROROARD <br /> FORM `A;W' <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> o <br />` SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE " F RtA <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANE SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE "J <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COM LETED) CD <br /> Co <br /> FACILV/SITE NAM A <br /> DRESS INFORMATION <br /> A1DR1 .^ NEAREST CROSS ST T40 <br /> o indicate 11 PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM t STATEZI SITE PH E#,WITH EAC E <br /> CA 0 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ".❑4 CESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS RESEATIONor ❑ ~ AT THIS SITE a <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: 14AME(LAST,FIRST) p PHONE WITH AREA CODE DAYS: NA E(LAST,FIRST) PHONE It ITH AREA CODE <br /> 33 - i" S 1q <br /> IGH S: N ME(LAST, I ST) PHONE#WIT AREA CODE NIGHTS: N ME(LAST,FIRST) PHONE#WIT AREA CODE <br /> �A �� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF DDRESS INFORMATION <br /> 1 �1A <br /> MAILING or STREET ADDRESS to indicate 1:1 PARTNERSHIP ElSTATE-AGENCY.'I `— CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> Oe'J t �'� [i' ' II❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY ME STATE e� ZIP CODE b 6 KRIP <br /> HONE91 AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) 6 C3` <br /> NAME CARE OF DDRESS INFORMATION <br /> A <br /> MAILIN •S BEET ADDRESSto indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> U CORPORATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME � ST�TIE ZIP CODE ' HONE J$.AVITH AREA CODE <br /> rK 6S <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 3 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> � I 1 11 EI I I 1101611hLL14 [ 416 1 Qh� <br /> CURT LOCAL �FACILITY ID# APPROVED BY NAME/ b � PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX (RATION DATE <br /> LOCATION CODE CENS RACT* SUPERVIS -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> I?4T7� YES NO 'f�' C! <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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />