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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD . <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I 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 3 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> i✓ r <br /> ADDRESS NEAREST CROSS STREET ✓Boxmi ❑ PARTNERNHIP ❑ STATE,AGov <br /> �ay ❑ noN 11LOMAGBKY ❑ H LAGEmx <br /> Lc ( O IL--- omouu ❑ COUWY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S>IV » CA O S U/L <br /> TYPE OF BUSINESS: ❑2,peRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID N If o1 TANK's <br /> ❑ 1 GASSTATION 3 FARM ❑ S OTHER TRUSTYLANDS RESERATION or ❑ L4ff— AT THIS SITE Q3 <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 /> S/g 4 -Tr <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> C ,./ c- os <br /> MAILING or STREET ADDRESS ✓B indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> a j J / - ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> l /j( INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP C DE PHONE N,WITH AREA CODE <br /> k -�V^ ,S <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S /gL TL T <br /> MAILING or STREET ADDRESS ✓Box di .W ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPC'ATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 13 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> I 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. ❑ 11. 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 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION R AGENCY# FACILITY ID N M of TANKS at SITE <br /> 3q = = I I 141 A Q 6) 0o3 <br /> 'y CURRENT LOCAL AfjENCY� jD M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER /'1l ,/\t O')�- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 19 3 YES NO i3 l p <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: w <br /> , I � <br /> WTHIS 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 <br />