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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> /LtP ..7FA <br /> W ^• w <br /> FORM 'A': V��.,y . �, <br /> UNDERGROUND STORAGE TANK PROGRAM = � o <br /> SITE - FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION t= <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'.��.a '" BCA <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1V <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S <br /> r <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> Of <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I <br /> nisi a <br /> ZZNdlisfred <br /> ADDRESS NEAREST CROSS STREET ✓Boa to iri .IA ❑ PARTNERSHIP ❑ STATEAGENLV <br /> gU� N • CI O d S ❑ CORPORATION Cl LOCAL AGEN ❑ FEDERAL AGENCY <br /> LlINDVIDUAL ❑ COUNTY'AGENCY <br /> CITY NAME 1 STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> �FoG�TO+-I CA q5r2n2 <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA IC p <br /> ❑ I GAS STATION [:] 3 FARM ❑ 5 OTHER TRURESSTYLANDS or 1:1A of TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH ATEA CODE DAYS'. NAME(LAST FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST FIRST) PHONE p WITH AREA CODE ' <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL CO3 COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> II <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 11 INDIVIDUAL ❑ COUNTYAGENCY <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. ❑ if. ❑ 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) PATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# I JURISDICTION# III AIGEN�CY# II FACILITY ID# #of TANKS at SITE <br /> H41 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BV NAME PHONE M WITH AREA CODE <br /> PAriSK-0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT <br /> # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (J <br /> 23, 6✓ YES NO /O <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESR THIS IS A CHANGE OF SITE INFORMATION ONLY. �( <br /> FORMA(3-2-88) p\z 1 U <br /> "W ?„ DATA PROCESSING COPY <br />