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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 5{'{ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> io <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^{�•o=�`" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION PERM LY CLOSED SITE Fa+ <br /> ONE ITEM 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S� -4 Url <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w <br /> C11 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e� <br /> ADpRE33 NEAREST CROSS STREET to mi ❑ PABINERSIIP ❑ STATE AGENCY <br /> S K CORPORATION 11LOCAL-AGENCY ❑ FEDEML AGM <br /> Q A/ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAyi I STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> aekfo� CA 3 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PflOCES50R ✓Box if INDIAN EPA ID x <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANOS ATION or ❑ � AT THIS SITEQK <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS NAIVE( ST,FIRST) PHONE If WITH AREA CODE <br /> amer <br /> fii u <br /> NIGHTS: ME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> e 20 2 020 til <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRES INFORMATION <br /> v <br /> MAILING or S BEET AD ESS ox w Indicate ❑ PARTN SHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 3/7 INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME / i STATE ZIP CODESI PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O INDIVIDUAL ❑ COUNTYAGENCY <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: I. ❑ It. ❑ <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 R JURISDICTION S AGENCY R FACILITY ID R N of TANKS at SITE <br /> 20 6C-2 <br /> CURRENT L,0 ENf�Y FrTYJij,1j.� APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER C/�'••J/" C7yU PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• 4SUPERVISOR-131STRICODE BUSINE38 PLAN FILED DATEFI D,3 YESNO <br /> PERMIT AMOUNTRCHA GE AMOUNT FEE CODE RECEIPT 0 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-&&) <br /> IVLAA�(Ta'/�/0/1I� `t' DATA PROCESSING COPY nqI <br />