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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': _ #�• <br /> UNDERGROUND STORAGE TANK PROGRAM Z�� to <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ 5 CHANGE OF INFORMATION ❑ 7 PERM ENT D SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ^ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S00 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <D <br /> FFACILII NAME CARE OF ADDRESS INFORMITIC ON <br /> f e!l' SO#'IS A I/ /L <br /> NEAREST CRO gTREET BMW ❑ PAMNEBRIIP ❑ STATEAGBO <br /> S /(� ❑ ATpN ❑ LOGL-AGE D ❑ FEDBA AGUAD <br /> S { a Lh Y l WAl ❑ O]UNIYAGENCY <br /> ME n STATE ZIPCODE SITE PHONE K,WIT�H�F� A CODE <br /> c CA F BUSINESS EPA ID M❑2 D UTOR ❑ #PROCESSOR ✓Box i1 T ON � � #oI TANK'#5 OTHER RESERVATIONor ❑ AT THIS SITE <br /> GASSTATION 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST TH <br /> PHONE#WIAREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. 12E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) (� PHONE p WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> J' � ><e //i d- Son s <br /> MAILING or STREET ADDRESS ✓Box to tate ❑ PARTNERSHIP 11STATE-AGENCY <br /> �/ !` El ORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> drre-lA Z_GL, SKINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#,WITH AREA CODE <br /> C4 gsa�a- <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 fj � - <br /> MAILINGorSTREETADDRESS ✓Bo dicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> N //P /�– ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / L r 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. ❑ IL 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 6) 1'61 101010 <br /> CURRENT LOCAL AGENCY FACILITY ID_#/y/ APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F <br /> l / 3 • YES NO 67j?—�' <br /> •' CHECK# PERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPT# BY: C <br /> `N 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 /> V' FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />