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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m ;1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> 7 LhueS Jwe-- <br /> ADDRESS //'' ��99/��� (� NEAREST CROSS STREET ewwate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 311 5 J j V 1Z& J/Q ❑ INDIVIDUAL Cl <br /> El COUNT(AGENCY L AGENCY ❑ FEDERAL AGEN <br /> CITY NAME STATCA ZIP CODE� SITE PHONE k WIT q CODE <br /> .S <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PRO fl ✓Box if INDIAN <br /> RESERVATION or EPA ID w R of TANK'e <br /> ❑ I GASSTATION ❑ 3 FARM EAKTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRI AR EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) L /�P}IiNE M WITH AREA CODE DAYS: NAME(LASE FIRST) p PHONE N WITH AREA CODE <br /> Of <br /> NIGHTS'. NAME(LAST,FIRSTV PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF A�ATION <br /> MARLIN/Cy/0),STREET ADDRESS ✓Box to In Jo.t. ❑ PARTNERSHIP ❑ STATEAGENCY <br /> (// 0� O ❑ INDIVIDUAL ON ❑ COUNTY-AGENCY El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PH�,WITH AREA C0� <br /> / p/ bJ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sw►� � <br /> MAILING or STREET ADDRESS ✓60x loindow. ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ I.W 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 a AGENCY a FACILITY ID a At of TANKS at SITE <br /> ® o / 10 1 f Isl Q 11, 1 (9 <br /> CURRENT LOCAL AGENCY FACILITY;FID APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> VY <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> POCAONCOE CENSU8TRACTX SUPERVISOR-DISTRICT CODE BUSINES P S NFILED NO ❑ DATE FILED ZAbsVio PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST It)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 01/LY. <br /> ORM A(3-2-88) \/) <br /> DATA PROCESSING COPY <br /> --1 .- <br />