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r <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q/ <br /> t0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/ ITE NAM , ,/� CARE OFADDRESS INFORMATION <br /> ri <br /> ADDRESS NEAREST NEAREST CROST ✓ wRo <br /> lidl. ❑ PARTNERSHP ❑ STATE AGENCY Cr) <br /> IO AGENCY Cl FEDERAL <br /> INDIVIDUA- ❑ COUNTY AGENCY2 /ap 0, 0 <br /> w <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE 'V <br /> CA s - <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑�4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> ❑ 1 GAS STATION ❑ 3 FARM bl 'OTHER TRUSTYLANDS or ❑ Q�� #of TANK'N / <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME( ST,FIRST PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> t 2D�j_ <br /> NIGHTS. NAME LASt FIRST PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY O NER I ORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA 11(�,n y� L, L CARE OF ADDRESS INFORMATION <br /> MAILING or STR ET PRESS /.,}ly; ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> VLV x � ❑ INDNIDUAL RATION Cl LOCAL-AGENCY❑ COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> CITU NAM:5 STATE ZIP CODE PHONE#,WITH AREA CODE / <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME `�. _ CARE OF ADDRESS INFORMATION <br /> rn e � <br /> MAILING or STREET ADDRESS ✓Be.m intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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.>Q Ill. ❑ <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 It AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® OCA / a 1 / CJccr <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE <br /> 1 v <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOtCODE CENSUSTRACT* SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED DFIL: E❑ Na <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> \�1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFO MATION ONS'(.' <br /> VVV FORM A(3-2-88) J\ <br /> Assisi DATA PROCESSING COPY <br />