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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> „ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> (� COMPLETE THIS FORM FOR EACH FACILITY/SITE .o �% <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE �N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ' <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAMEW <br /> CARE OF ADDRESS INFORMATION C4 <br /> /'J7/!v C4/ f r W <br /> ADDRESS NEAREST CROSS STREET ✓BmbedoN ❑ PARRERBW ❑ UATE AGENCY <br /> ❑ COW0RATDN ❑ IOC&AGENCY ❑ FEGFRV AGEwx <br /> ❑ wormA ❑ ORNTrAGDAY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA 95-d0a av 9 vY -s 7/ <br /> TYPE OF BUSINESS L]2 DIsmBL TOR ❑ N PROCESSOR I ✓Box it INDIAN EPA ID N <br /> ❑ 1 GIS STATION [:]S FARM ❑5 OTHER TR USESERT or of TANK's <br /> ❑ C �O 00 (�Y/ B AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 617 , 'ah -9vv - s?/ <br /> NIGHTS NAME T,FIRS PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S/A S/!* <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A&lel 6/5 he <br /> MAILING ar STREET ADDRESS , I ✓ x W indicate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> ❑ "Cate <br /> ❑ COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> C4 1 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /'yl r(/' �— <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> © O /_ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> C4 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE)1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS of SITE <br /> 9 o1 i 1 0 1 v 1 7 01 0 1 01 o <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH MEA CODE <br /> / CA " <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I' <br /> LOCATION CODE CENSUS TRAACTS SUPERVI OISTRICT ODE I BUSINESS PLAN FILED DATE CODERECFILED// y <br /> OO YES ❑ NO ❑ /O/,j1P/ <br /> CHECKS PERMIT AMOUNT SURCH GE AMOUNT FEEEIPTS BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST"I nR MORE TkNKPERMIT FORM 'B'APPLICATION(S), UM"S THIS IS A CHANGE OF SITE INFO ATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />