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STATE OF CALIFORNInr WATER RESOURCES CONTROL-BOARD <br /> 5"` 'hf <br /> A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM I <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATti Cl <br /> COMPLETE THIS FORM FOR EA7 FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITNAME CARE OESS INFORMATION <br /> At M �- MX <br /> m <br /> ADDRESSNEAREST CROSS STREET ✓BmbMiom, D PNiM611? D STATE-AG016Y <br /> /J /'-fQ ❑ CORPORATION ❑ LOCAL AUNLY 13FEDERAL.KaICY <br /> (Jr <br /> / �/ / D ❑ INMIDUk 0 COUNTf AGENCY <br /> CITY NAME STATE ZlWCODE SITE PHONE N.WITH AREA CODE <br /> c 0 m P-02 CA Q55 Zb <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOfl ✓Bax if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS ATION Gr ❑ S of <br /> AT THHISIS 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 LADE <br /> NIGHTS: NAME BAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D 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 /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ If. ❑ <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 /> C,ODU�NT/Y R JURISDICTION R AGENCY X FACILITY ID N E of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE•WITH AREA CODE <br /> PERMIT NUM1481hp PERMIT APPROVAL DATE EPERMIMPIRATION DATELOCATION CODE CENSUS TRACT N SUPERVISOR•OISTRICT CODE N FILED DATE ILED <br /> ��� ? NO � I� 6 O <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Y: <br /> r\ <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 13-2-88) <br />