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STATE OF CALIFORNIA`S WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V � <br /> imp roo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 2<CHANGE OF INFORMATION ❑ 7 PERM/A LY CLOSED SITE F"+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE `t• 3 IV <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r t 13 d �s0 Qin G <br /> ADDRESS NEAREST CROSS STREET ✓Aoxm mi ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 3 Qj yT OA TION ❑ LOCAL-AGENCY ❑ 111 AGENCY <br /> MDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ^f� STATE ZIP 0,5 SI OHONE p,W TH AREA.CODE <br /> TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 N ((� NK 3 <br /> ,2 i <br /> RESERVATION or #of TANK1 <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> he f, <br /> �a r SSo <br /> MAILING or STREET ADDRESS ✓Box m indicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> .wrte' ❑ CORPORATION 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r e� ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> GTY NAME ST�/0 ZIP CODE <br /> D PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CAREOF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY10, JURISDICTION M AGENCY k TY ID- R of TANKS at SITE <br /> Ml D <br /> CURRENT LOCAL AGENCY FACILR IL./ ,/) L it 3 A ROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER ////( OV+AALL DATE PERMIT EXPIRATION DATE <br /> 7wl <br /> LOCATION 9,01DE CENSUS TRACT SUPERVISOR-DISTRICT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAEFILED <br /> 3 oL 3 YES NO <br /> CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />