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STATE OF CALIFORNR WATER RESOURCES CONTROL BOARD <br /> a <br /> FORM `A': ° <br /> UNDERGROUND STORAGE TANK PROGRAM ="� �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I c <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ER.5 CHANGE OF INFORMATION ❑ 7 PERM NTLY REDSITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �3 � <br /> CT? <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) v <br /> FACILITY/SITg NAME CARE OF ADDRESS INFORMATION I' <br /> 6tZrfJ c-kr Wrl�kwn S=Yck <br /> ADDRESS NEAREST CROSS STREET ✓1011vbr]P 0 PARRERSW 0 STATE AGOY,Y <br /> Aa UfCN o CDWMnM °a �. c ° EOEAA.ABBq <br /> CITY NAME callic STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> (:�lf CA ?5552 9v 2�`r-?Y8—elZy <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ESERVATION or ❑ EPA ID N N of TANMN <br /> ❑ I GASSTATION ❑3 FARM �S OTHER TRUST LANDS AT THIS SfTE <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 <br /> c f(Ctm 20f?_? _612_ aik/'/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Ols0 - am <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING v STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sr4A.[1!F X-5,4- <br /> MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1.0II. ❑ 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 /> COUNTY N JURISDICTION N AGENCY N FACILITY ID R Y of TANKS at SITE <br /> NE = = 10101ZIC-) -7 161 1010 10 a <br /> CURRE LO�C�-AyL-A�GENCC-Y-FACILITY ID• APPROVED BY NAME PHONE N WITH AREA CODE <br /> �� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UPIRAT10N DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 r'O L YES NO <br /> CHECK t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 1 J3 <br /> 111 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(3-2-813) <br /> �� � DATA PpOCE531NG COPY <br />