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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD *� <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE 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 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> N I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) V <br /> FACILITy/$ITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ^ NEAREST CROSS STREET ✓Bat,YIWA D PAFINERSNIP Cl STATE AGENCY <br /> )� / Cl CGRPORATION D LDCAL EN ❑ FEDERALAGENCYi <br /> (Oy V\ /VAYAL l�� ( C INDINIDUAL D COUNTYAGENCY <br /> CITY NAME /� q / STATE ZIP CO SITE PHONE p,WITH AREA CODE <br /> L\f�/I(//1 Y�L(.JG.y..`—', cA <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 P ESSOR ✓Box if INDIAN EPA ID a #of TANK'N <br /> ❑ E] RESERVATION or 1:1AT THIS SITE <br /> F-11 GAS STATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a Cao!&f5 - 198' <br /> NIGHTS NAME(IAST.FIRST) PHOITE WITH AREA CODE NIGHTS'. NAME(LAST,FIRS ONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & A DRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓80x to iTdicate D PARTNERSHIP ❑STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — ( UST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inoicate D PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION Cl LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL Cl 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 B H LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN t <br /> TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® � 1010 1 1= old <br /> / CURRENI AGENCY FACILID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER 1Y1V/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN8U8 TRACT# SUPERR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �(.�J <br /> YES NO ❑ — I k <br /> (� CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> G1\�, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(]J OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNI ESS THIS IS A CHANGE OF SITE INFORMATION ONLY rl) <br /> FORM A(3-2-88) p <br /> �, �� DATA PROCESSING COPY <br />