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Pt <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ro. <br /> W \J• <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMf� <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> G <br /> � <br /> y COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ILS{1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D , <br /> IC <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> rNa <br /> ADDRESS NEAREST CROSS STREET V 1111 iTdi[alePARTNERSHIP ❑ STATE AGENCY C" <br /> n /NO ElCOFORATION .i(OCALAGEND 0 FEDERAL AGENCY <br /> L0 1 0 INDIVIDUAL ❑ COUNT(AGENCY Q <br /> CITY NAME. STATE ZIP CODE SITE PHONE N,WITH AREA CODE w <br /> `J CA S <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or #of TANK'N <br /> ❑ 1 GAS STATION ❑ 3 FARM ®'5 OTHER TRUST LANDS ❑ Q n AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST F ')T) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Wer I - 3 0 <br /> NIGHTS'. NAME(LAST,FIR PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 50.Ie-, <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to Indicate n 2ARTNERSHIP 0 STATE-AGENCY <br /> $/-Z7 C. A4LL1ti��{ 0 CORPORATION IMLOCAL-AGENCY 0 FEDERAL-AGENCY <br /> OSS C NAL W. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME • STATE ZIP CODE PHONE N WITH AREA CODE <br /> - <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME fil�, CARE OF ADDRESS INFORMATION <br /> LI rde <br /> MAILING STIFF T ESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> //�� <br /> 13 CORPORATION OOAL-AGENCY Cl FEDERAL-AGENCY <br /> + A � 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ it. pw�- Ill.❑ <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# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> ® � O � I l 1 4? �?- 3 16 10o <br /> 1 ECURRENT LOCAL(LGENj ¢TYIDN APPROVEDB MPHONE#WITH AREA CODE <br /> T / Na y <br /> PERMIT NUMBER <br /> PERMIT <br /> APPROVAL DATE <br /> p� RITMEXPIRATION DATE <br /> ,2OV—O ATa <br /> LCHECKO <br /> E CENSUS TRACCTT/N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Gd <br /> 23• ZS O I� YES <br /> PERMIT AMOUNT <br /> Is <br /> 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 x,f <br />