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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': � <br /> UNDERGROUND STORAGE TANK PROGRAM = " �o z <br /> SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN LOSED SITE r <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q � <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) Hsi. <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> P <br /> ADDRESS NEAREST CROSS STREET ✓BaWEGIam' ❑ FAPTNERSHIP ❑ FATEAGEN <br /> 3A (YG RPOMTION [3LOCAL AGFNCf ❑ FEDERAL-AGENCY <br /> "- ❑ INDNIWAL ❑ COUNIY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA 953 - 6 <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR ❑ a PROCESSOR ✓Box if INDIAN EPA ID n #of TANK'Y <br /> GA$STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETLANDSATION o ❑ AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST.FIRSTI PHONE N WITH AREA CODE <br /> ti g -037 dc, / p�� s- <br /> NIGHTS: A E(LAST. RST) HONE p WITH AREA CODE NIGh o. rv✓.mt,I AST,F�) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> IV IO O((- CU <br /> MAILING or FEET ADDRESS ✓ o dAT,te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /`� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> c OQ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE I <br /> �ti�� c Dos <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> )&JOCAL <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ ATE AGENCY <br /> n I - ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> L ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> W�ltiui q <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: 1. ❑ II. ❑ 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 /> COUNTYIN JURISDICTION B �AGENCYII�R III FACILITY ID# a o1 TANKS at SITE 1 <br /> LJ� O I V O 1 <br /> CURRENT LOCAL AGE. NOJ'FACILITY II.D# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER �`// ,1v` PER MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> C, Z3-9 <br /> 0 <br /> Z YES ❑ NO ❑ 117.3—" <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 NLY. <br /> FORM A(3-2-88) / <br /> `W NOW DATA PROCESSING COPY �� / <br />