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�./ 5ra�..af <br /> STATE OF CALIFORNIA` WATER RESOURCES CONTROL BOARD �" `"" <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> �; to <br /> f COMPLETE THIS FORM FOR EAC FACILITY/SITE ��`-'-`—"�� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE rV <br /> cA <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE111 0) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A S: 50 -O/—5 C2 <br /> FACILITY/SITE NA E CARE OF ADDRESS INFORMATION 666 <br /> y <br /> ADDRESS �1 1 NEAREST GROSS STREET ✓60,10 md.le ❑ PARTNERSHIP Cl STATEAGENCY <br /> q73 '7730 /`� • G/�GrII� ❑ CORPORATION ❑ COUNTY <br /> ❑ FEDERAL AGENCY <br /> 1✓ ❑ COrvlouat ❑ LOCAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA Qz i� 2 <br /> TYPE OF BUSINESS'. El 2 STRIBUTOR ❑ 4 PROCESSOR RI/Box,f INDIAN ESERVATION or EPA ID # #of TANK's <br /> 1 GAS STATION FARM ❑ <br /> 5 OTHER TRUST LANDS ❑ 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#WITH AREA CODE <br /> t Arked ,2 -b b 8' <br /> NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /— CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDREBS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> [I CORPORATION 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �' 11INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME �� STATE ZIP CODE PHONE#,WITH AREA CODE <br /> /ry5236 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. V I. ❑ 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# JURISDICTION It AGENCY# #o1 TANKS at SITE <br /> ® 3 3 v <br /> CURRENT LOCAL APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER IT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC TION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> 23 Z �� YES ❑ NO 110 <br /> CHE KN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE PIECED PTN BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R MIB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> L 1 O DATA PROCESSING COPY <br />