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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> I f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® r. o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> C'rlliORN\P <br /> MARK ONLY ❑ 1 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 CLOSUREIF() <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) v 4�k <br /> FACILITY SITE NAME / , CARE OF ADDRESS INFORMATION co <br /> j'Y��.✓ N/ <br /> ADDRESS NEARE CROSS STREET �✓ bnEi ❑ PWTNHIS4IP Cl STATE AGENCY <br /> /Z/ 4d'COf80RAMM ❑ LOX AGDO ❑ M)EIAL AGEID <br /> /`C�l ❑ INOMWAL ❑ C0oNlY AGENCI <br /> CITY NAMESS STA ZIP CODE ITE PH NE N,WITH AREA CODE <br /> CA �7 l? <br /> TYPE OF BUSINESS: <br /> ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA 10 N <br /> ED-t-W STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or ❑ M of TANK'* <br /> LANDSL.) 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,FIRST) PHONE N WITH AREA CODE 4biA (k) <br /> `I S - G I/ 14 <br /> NIGHTS: NAM ( T,FIRST) PHONE It WITH AREA CODE NIGH S: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> '/ C3`� S <br /> II. PROPERTY OWNE *FOR ATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box l.,,,d, ale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRES INFORMATION <br /> A WA'ST <br /> MAILING or ST ✓ to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /✓/ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STATE DECODEPHONEp,ZWITH AREA CODE <br /> IV. LEGAL LN/OV/TIIFFFICATION AND BILLING ADDRESS G /// <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 /> COUNTY R JURISDICTION N AGENCY N FACILITY ID N R of TANKS at SITE <br /> CURREFACILITY IDN APPRO <br /> NT LOCAL AGENCY VED BY A PHONE N WITH AREA CODE <br /> (L 1S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAED p <br /> Z 3 . YES NO -.27 0 <br /> CHE K PERMIT AMOUNT SURCXAR EAMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM SBI APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-89} <br /> ,►AW DATA PROCESSING COPY <br />