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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': V s'. I <br /> UNDERGROUND STORAGE TANK PROGRAM oi <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARKONLY ❑ I NEW PERMIT � 3 RENEWAL PERMIT �6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE IT <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) F00 <br /> -` <br /> FACILITYBITE NAME CARE OF ADDR S INFORMATION <br /> ADDRESSNEAREST CROSS STR ✓9m to ret Cl PARTNERSHIP 0 STATE AMD <br /> 3 1 DOMC�o 0 CORPORATION 0LOCALAGENCY Cl FEDERAL AGENCY <br /> Ni 0 GCII—AGENCf <br /> C / SITE PHONE a,WITH AREA CODE <br /> CITY NAr STATE <br /> CA / <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUT ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID a M of TANK'a <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. AME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. %AME(LOST,FIRST) PHONE#WITH AREA CODE <br /> Di <br /> UKN <br /> NIGHTS' NAME(LAST.FIRST) PHONE p WITH 9HEA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> if, <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME p CARE OF ADDRESS IN MAT ON <br /> MAILING or STREET ADDRESS � yp ox to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> / Q N� ORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> q033 Un Imo+ INDIVIDUAL 0 COUNTY-AGENCY <br /> CI NAME S ATE ZIP CODE PHONE a,WITH AREA CODE <br /> k►v - 3I-z9�s2 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /Q CARE OF ADDRESS INFORMATION <br /> rw <br /> MAILING or STREET ADDRESS -/B..W.ndicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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. ❑ IlaIII. <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 M AGENCY M FACILITY ID Al R of TANKS at SITE <br /> E 10 lo I / I S k 10101001 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> � <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTa SUPERVISOR-DISTRICT CODE BUSINESS,SN FILED NO <br /> DA EFIL D <br /> 2 O ❑ ❑ YSM C44 <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> .iiii . DATA PROCESSING COPY <br />