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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : to <br /> LLCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANEU11 Y LOSED SITE I"J <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 00N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cc <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> � es VI <br /> ADDRESS NEA E TCROSS STREET ✓Sm loiMicak ❑ PARTNERSHIP ❑ STATE AGMD <br /> ❑ L ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 1 V W f �V NDUAL ❑ COU"AGENCY <br /> jCIN NAME STATE ZfP CODE SITE PHONE il.WITH AREA CODE <br /> CA Sas <br /> TYPE OF B (NESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or Mol TANK' <br /> s <br /> GAS STATION ❑ 3FARM ❑ 5OTHER TRUST LANDS 1:1 <br /> AT THISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> `f,�eA1J,.sN� g3E, <br /> NIGHTS: NAME(LAST,FIRST) PHO)#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME(^^ •Cry _ 1 CARE OF ADDRESS INFORMATION <br /> Tej <br /> MAILING or STREET RESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> iI ^/� _ ❑ CORPORATION [3LOCAL-AGENCY ❑ FEDERALAGENCY <br /> C-00 W U•/� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �� STATE ZIP CODE PHONE if.WITH AREA CODE <br /> III. TANK OWNER INFOROATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME �^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CXECK 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 M JURISDICTION# AGENCY# FACILITY ID M M o1 TANKS e1 SITE <br /> 10101 11 S D 1010 <br /> CURRENT LOCAL AGENCY FACIL TY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI J ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> G` YES NO � <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> FORM A(3-2-88) <br /> iIBB' DATA PROCESSING COPY >� <br />