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T'" 7 <br /> I <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITErc_I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 P T LOBED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE s, <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) to <br /> FACT TY/SITENAME CARE DRESS INFORMATION <br /> ADDRESS ' NEARE T ROSS STREET ✓Ho to iMPala 13PARTNERSHIP 11STATE AGENCY N <br /> Z RPOMTn ❑ LOCAL ❑ EEDBULAGENCY <br /> NCY 4111, <br /> CITY NAME STATE ZIP CODE INGMGWSITE PH❑OEB WITH AREA CODE 4mb <br /> L401, <br /> CA V"yO <br /> TYPEOFBUSINESS: ❑2 DISTRIBUTOR ❑4 P CESSOR I <br /> RV Box if ESERVATION INDIAN EPA ID n Not TANK' <br /> a /� <br /> ❑ 1 GAS STATION ❑3FARM SOTHER TRUST LANDS ❑ 4 ATTHISS% (IO <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) j <br /> DAV •NAME(LAST,FIRST) HONE N WITH AREA CODE DAYS: AME(LAST,FIRST) PHONE N EA CODE <br /> 3bs1'- 78lva <br /> NIG NAME(LAST,FIRST) - PHONE M WITH AREA CODE NIG AME(LAST,FIRST) PHONE p WI REA CODE <br /> Zv a7 <br /> 11. PROPERTY OWNEW INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFA pESS INFORMATION <br /> MAIL or TREET ADDRESS ✓Bax to irdicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O-CO <br /> RPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> [T INDIVIDUAL ❑ COUNTY-AGENCY <br /> CI IYM STpT ZIP COCK PHO# # ITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARED AGREES INFORMATION <br /> MAILI r BEET ADDRESS Box to iWicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> OiCORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> [� INDIVIDUAL COUNTY-AGENCY <br /> CITY N9MFj STT ZIP O PHO# ,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: t. 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'S NAME(PRINTED&SIGNATURE) DATE 111 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID a a of TANKS at SITE <br /> m 10 (� ' dU D b <br /> CURRENT LOCAL AOENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENBUSTRACTTTVISR- <br /> N SUPERDISTRICT CODE BUSINESS PLAN FILED DAT' <br /> Z Z3. <br /> FPO YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <br /> I <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-&B) <br /> l.4 DATA PROCESSING COPY S <br />