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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ""' ` <br /> a <br /> FORM `A': . . <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Cir 1-ro L- Gv' r <br /> ADDRESS U / < {/}� IM <br /> n NEAREST CROSS STREET emimlure ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPO1 ` J♦ / 14 Iw P-44 Cl NGNDUA�ION ❑ �ryAGEHC L AGEND ❑ FE➢EAALAGENCY <br /> CITY NAME s-rv— STATE ZIP CODE �0 SW;p .W!}IOD // 1I <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR PROCESSOR ✓Box if INDIAN EPA IDaRESES //`/#ol Tl/ArINK't 6G <br /> TRUSTLANDS <br /> or ❑ <br /> ❑ 1 GAS STATION ❑ 3 FRAM S OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRSTPHONE N WITH AREA CODE <br /> 7 - 6 - S) <br /> NIGHTS: NAME LAST,FI t <br /> ) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sh� <br /> MAILING or STRE&ADDRESSIo indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> 1�1/ ❑ CORPORHAT[ION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATEZIP C E PHONE#,WITH AREA CODE <br /> Suti �RdWIUS� Ge. 1 IL <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a <br /> MAILING or STREET ADDRESS ✓Box to inaioate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> Cl INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.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. 111.❑ <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 /> COUNTY41 JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> 6 b I 1010101 / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT#�v SUPERVISOR-DIST CODE BUSINESS SN FILED NO <br /> ❑ DATEILED / <br /> b Z /7L <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST t1)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 />