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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COM% THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAMEkPHONE#WITHZEU_C0DE <br /> CARE OF ADDRESS INFORMATION <br /> N <br /> NEAREST CROSS STREET ✓Eoxto mvaB ❑ PAFTNEAS4IP ❑ STAIEAGENCi <br /> ADDRESS Cl COAPGRATIGN ❑ IOCALAGENCY ❑ FFDDlA4AGDKY �y <br /> ❑ INOIVIGUAL ❑ COUNTY-AGENCY !I lvr <br /> STATE ZIP CODE J SITE PHONE a,WITH AREA CODE <br /> Cl NAME CA <br /> TYPE OF BUSINESS: Z DISTRIBUTOox tl INDIAN ❑ EPA ID a a of TANK'a <br /> RVATION or AT THIS SITE D <br /> 7 GAS STATION 3 FARMT LANDS <br /> EMERGENCY CONTACT PEREMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS: NAME(LAST,FIRST) <br /> WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> uELt ' QNIGHTS' NAME(LAST,FIRST) WITH AREA CODE NIGHTS: NAME( T,FIRST) PHONE a WITH AREA CODE <br /> II <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> lye HE a <br /> M LING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> _BPORAT ❑ OUNTV AGENCY ❑ FEDERAL-AGENCY <br /> LOCAL <br /> CITYNAME STATS ZIP CODE PHONE a,WITH AREA CODE <br /> C0 tiJDN <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDS;INFORMATION <br /> AtIU <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> PORATION 1:1 LOCAL-AGENCY ElFEDERAL-AGENCY❑ <br /> L DIVIDUAL (:1 COUNTY-AGENCY <br /> GITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> ,L/ CA I 95203 0Ne <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. 0 IL 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 77771 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY a FACILITY ID a a of TANKS at SITE <br /> Ew = 00 <br /> CURRENT LOCAL AGENCY FAG ITY ID a APPROVED BY aN E n`/ PHONE K WITH AREA CODE <br /> D b Q <br /> PERMIT NUM131M PERMIT APPROVAL DATE PERMPf EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M I Sit PERVIeOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO ❑ <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(9-2-88) <br /> DATA PROCESSING COPY �� <br />