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091 <br /> f <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ®.7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE`NAME -p I/ CAREOf ADDRESSINF RMATION <br /> dCR dN /J IJ(1�7e �1 p <br /> ADOREBBn - NEARESTC OSS STREET ✓Bovgcobbtliak ❑ GAATNEASHIP I] STATE-AGENCY <br /> 02 dt N ❑ INDQUA`ION ❑ WUNIY^GENCYAGMGf ❑ fIDFAAI AGENCY <br /> CITY NAM STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> ae FoN CA 1 ?ss Z06 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # I� M of TANKY ' <br /> TRUSTVLANDS or ❑ U I� N <br /> ❑ i GAB STATION ❑3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(UST,FIRST) PHONE P WITH AREA CODE DAYS: NAME LAST,FIRST) PHONE A WITH AREA CODE <br /> a 204-4/6 -83 U p <br /> NIGHTS' NAME(LAST,FI ST) PHONE a WITH AREA CODE NIGHTS. NAME ST,FIRST) PHONE N WITH AREA CODE <br /> 4 - -SL88 <br /> H. PROPERTY OWN INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME y� CARE OF ADDRESS INFORMATION <br /> a I�ae <br /> MAILING or ST EE7 ADDRES ✓ ox to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> 3 I /� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (7 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME <br /> � ST� A ZI s� ��` `�� <br /> ODEPHONE ITH C �� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> �,Q)(,t� � <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,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. ❑ If. vr 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 R JURISDICTION If AGENCY* FACILITY IDR N of TANKS at SITE <br /> 00 1 E= OC) 10 1 1 <br /> CURREI 49CAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA`CCT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 a p Z� YES NO /2 <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It 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 <br /> F RM A(3-2-88) <br /> DATA PROCESSING COPY <br /> \/ *.W/ <br />