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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD h�`""`' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SSTFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PE ANENTLY CLOSED SITE F"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3to <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) LN► <br /> FACILITY/SITE NAME x CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ IoildiGk ❑ PARTNERSHIP Cl STATE AGENCY <br /> 3 (7 OU <br /> ElLOCAL-AGENCY ❑ FEERALAGENCY <br /> e <br /> J, a h`o"nr INDWIDUAL O CaxmAGENCY <br /> CITY NAME ^ STATE ZIP ODE SITE PHONE#,WITH AREA CODE <br /> J CA 6-5 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BoxE'ER if INDIAN EPA ID N A of TANMN <br /> ❑ 1 GASSTATION ❑3 FARM [elOTHER TRUST RESERLANDS ATION Or ❑ ATTHIS 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 <br /> 13 <br /> t �e a - is <br /> NIGHTS: NAME(LAST.FIR ( HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S Sim 7a577/Y­ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �ctveRA ri en rE iC Val <br /> MAILING or STREET ADDRESS / L(St ✓ ox to intlicate 0 PARTNERSHIP ElSTATE-AGENCY <br /> r <br /> p CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> LeX; 14d o ❑ INDIVIDUAL ❑ COUNTY-AGENCY ' <br /> CITY NAMEQ STATE ZIP CODE PHONE N,WITH AREA CODE <br /> N <br /> III. TANK OWNE NFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION ,, <br /> S 0 rn e4q s f er <br /> MAILING or STREET ADDRESS ✓Box to India to ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. ❑ Ill. ❑ <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 R AGENCY S FACILITY ID a S of TANKS at SITE <br /> = = = 10101 / 57TE o0oo <br /> CURRENT LO L AGENCY FACILITY ID N APPROVED BY NAME PHONE K WITH AREA CODE <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0,3, a 1041YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT K BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-68) — <br /> DATA PROCESSING COPY <br />