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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> FaCOMPLETE THIS FORM FOR EACH FACILITY/SITE `'"•oa—"-�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA Y CLOSED SITE I"� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C <br /> F-L <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Pum ST emer <br /> ADDRESS NEAREST CROSS STREET ✓Bw0voca, D PAIMEPIMIP ❑ STAMAGENU <br /> {Al QKIQ OD INp IDUUk OD LWGUIIYAGP�ICY ❑ HX0.IL AGF* <br /> CITY NAME If STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> '-KW CA X06 7,0ct—et66 —7-09# <br /> TYPE OF BUSINESS. ®p DIS7flIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID p <br /> ❑ I GAS STATION ❑ 3 FARM ❑ S OTHEfl TRUSTVLANDS ATIONor ❑ AT THIS SITE 2 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> /J <br /> NIGHTS: NAME(LAST,FIR T) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> 1•rc ZO?— _ �1191491 U NJ <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 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*,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP D STATE-AGENCY <br /> I ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY MAM1E STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> e 5206 66- oY/ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WMICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND 41I14GJ I. II 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY K +LEDGE,1 UE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION a AGENCY a FACILITY ID a a of TANKS at SITE <br /> Ell E:= lololililqlv I lololol -2d <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE*WITH AREA CODE <br /> RBG Iq <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAACT M SUPERVISLO.R/-DISpAT�RICT CODE BUSINESS PIAN FILED DATE FILED <br /> 2 3 V /.2 ) YES ❑ NO ❑ g G-H <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST III OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) 1 <br /> �• DATA PROCESSING COPY �! <br />