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STATE OF CALIFORNI)r WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM VmY ' <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �o Z I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ir] 1O <br /> ��4FortN.P <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT <br /> ONE ITEM CHANGE OF INFORMATION T pEq <br /> 2 INTERIM PERMIT ❑4 AMENDED PERMIT - LOSED SITE FA, <br /> ❑6 TEMPORARY SITE CLOSURE O - <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACIL{TY/SITE NAME 0 <br /> L <br /> CARE OF/A DRESS INFORMATION <br /> ADDRESS N <br /> 10 <br /> NEAREgT CROSS STREET ✓3m IOMdiCdk wNSRSHIP ❑ STATE <br /> ❑ CORPGRAiIGN ❑ LGCAL#GENCY ❑ FEDERALAGENCYCITY NAME ❑ INDIVIWAI ❑ CGGNIYAGENCI <br /> LU STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> TYPE OF BUSINESS CA .S"Zt/6 t,..vt4t-_. <br /> 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID�N <br /> ❑ I GAS STATION FARM ❑ 5 OTHER TRUSTLANDSo ❑ A-11A A of TANK'# <br /> AT THIS SITE 6 b li <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS NAME(LAST,FIRST) <br /> SPHONE N ITH AREA CODE <br /> NIGHTS AME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: AME(LAST,FIRST) <br /> S ���✓_��/�L��� PHONE p TH AREA CODE I <br /> Ir <br /> IA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ]� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to',Id, o ❑ PARTNERSHIP 11STATE-AGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,Td,..te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY N FACILITY IO N N of TANKS at SITE <br /> = = jQj0jqj7bjjE [ 6111101 () I_ <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY AME p PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ^/ <br /> LLOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSPLAN❑FILED NO �ABATE <br /> FILED <br /> / /� <br /> 3 ,Z3 ?,o <br /> 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 /> FORM A(3-2-�88)" <br /> DATA PROCESSING COPY `PN <br />