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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u �o <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> (/ COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 17CHANGE OF INFORMATION ❑ 7 PERMA CLOSED SITE 7y <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ Q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a •O <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e%S co f� <br /> ADDRESS C LNEARESTOSS STREET ✓90 Wollo , ❑ PAAINRSNIP ❑ STATEAGENC(ja60- C• ❑ COP TIGN ❑ LOCALAGENLY ❑ FEOEMLAGENCY <br /> ❑ INGNDLIAL ❑ CDArY AGENcrCITY NAME ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S a/or <br /> TYPE OF BUSINESS. E:j2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz it INDIAN EPA ID# <br /> ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or - Mo1 TANK's <br /> TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I'/+-L .SR/"LQ <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME a CARE OF ADDRESS INFORMATION <br /> `t ivrL <br /> MAILING or STREET ADDRESS �✓Box to m icaa ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LJ $`.ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> u tr <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa. Lt as Z- <br /> MAILING or STREET ADDRESS ✓Box Iyr�d ate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /( U ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 9'iNDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE p,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. II. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCYTV FACILITY ID R X o1 TANKS at SITE <br /> EE = = p Z) 1 4 13 13 1 ,96 1 p 1 O 1 o <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE♦WITH AREA CODE <br /> _ L 3 f <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPE VISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED/ <br /> 0� cZ 3oa3 _3a6 YES [-] MJ ❑ W90 <br /> CHECKF PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIM A BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORF TANK PERMIT FORM'B'APPLICATION(S), UNEBF THIS IS A CHANGE OF SITE INFORMATI , <br /> FORM A(3-2-813) <br /> .,/a-�b DATA PROCESSING COPY __01 <br />