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STATE OF CALIFORNIA — WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a o <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 ERM Y CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 1 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �� a) <br /> N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) f+ <br /> FACILITY/SITE NAME LKle CARE OF ADDRESS INFORMATION <br /> 2 /ajG7i <br /> ,r e �/ NEAREST CROSS STREET PAWNWIP GEICf <br /> C COWD RATION C LOGQ�AGI MX Cl STfE➢�1L M <br /> ADDRESS t -7 -700 Nr ✓/`LIRA-/" <br /> ❑ INNYOULL ❑ CWNIYAGBIC/ <br /> CITY NAME STATE 21P CODE SITE PHONE M,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS'. 2 IBUTOR /PROCESSOR ✓Box if INDIAN EPA ID A _ N o1 TANKe <br /> RESERVATION or AT THIS SITE <br /> I GAS STATION 3 FARM � 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST.FIRST) PHO WITH AREA CODE DAYS'. NAME(LAST. FIRST) PHONE N WITHAREACODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE R/WITH AREA CODE NIGHTS: NAME(LAAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> lj�e a 5 <br /> MAILING or STREET ADDRESS ✓Box toinoicale C PARTNERSHIP Cl STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / ( CARE OF ADDRESS INFORMATION <br /> µJ <br /> MAILING or STREET ADDRESS ✓Box(.indicate C PARTNERSHIP Cl STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. ❑ 111. <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY IDR R o1 TANKS M SITE <br /> b / O- 3 <br /> CURRENT LOCAL AGENCY FACIIf APPROVED BY NAME PHONE R WITH AREA CODE <br /> f—r <br /> PERMIT NUMBER E L PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> rCHECK <br /> N CODE CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 2-_=3 <br /> YES E] NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTII BC <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY `\J\ <br />