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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE '`��s^"`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) °o <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A2 A)e Dlt CS acC e t M <br /> ADDRESS NEAREST CROSS STREET ✓Boal indaile ❑ FARE <br /> HI ❑ STAT GENCI N <br /> �I , / V A/I ❑ COR ORATION 0 LOCAL-AGEND 0 FEDERAL AGENCY -,4w ' <br /> 0 INDIVIDUAL 0 COUNTY'-AGENCY CA <br /> CITY NAME STATE 71P CODE SITE PHONE N.WITH AREA CODE Q <br /> 112A G CA Z <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID X <br /> ❑ I GAS STATION ❑ 3FARM FlSOTHEfl TRUSTESEYATION LANDSo ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) PHONE XWITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> aQ� <br /> NIGHTS'. NAME(LAST,FI ST) PHONE p WITH AREA CODE NIGHTS. AME(LAST FIRST PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ES <br /> ADDRS ✓Be.Io intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Q �' 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE <br /> Vl o X15353 C } G535 3 -Sl-) <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME -� CARE OF ADDRESS INFORMATION <br /> 1_2ifm,c7 A-5 <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 71P CODE PHONE X,WITH AREA CODE <br /> TI N <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> D ESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. 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 N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SIT <br /> U o 16 <br /> CURRENT LOCAL AGENCY FACILITY ID,N APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DAAT,(E /�/ PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> 7)4�) YES ❑ NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNf FEE CODE RECEIPT X /By: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> r�f FORM A(3-2-88) - <br /> �� DATA PROCESSING COPY �I <br />