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4E'.vot rM1� <br /> STATE OF CALIFORNI)v WATER RESOURCES CONTROt'BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z { <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> :T COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'J <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURED -4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) W <br /> M-� <br /> FACILITY/SITE NAME r p CARE OF AD RES INFORMATI N,, I <br /> ESCR - C d ti W Ne s <br /> ADDRESS�J r I- NEAREST CROSS STREET ✓ftWo,m Cl PAMERSNIP 0 STATE AGENCY <br /> —7OI .3 G�lAION e 0 WWRATIGN 0 LOGLAGBKY 0 FEARAI.AGEIV <br /> NIm 0 WJNTIASDICY <br /> CITY NAME STATE CODE SITE PHONE N.WITH AREA CODE <br /> ttr G w CA 53PZ o 20? (e <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ <PROCESSOR R✓Box ii INDIAN EPA ID x R of TANKN <br /> ESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 38-33� Ul_t� <br /> NIGHTS'. NAME ILAST,FIRST) HONER WITH AREA CODE NIGHTS' NAM (I-AST,FIRST) PHONE N WITH AREA CODE <br /> Nes N Zd -M _3>3u AN <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NA�aCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> O_g <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID R R of TANKS at SITE <br /> ® 10 d 10 1 a 10 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECKO <br /> E CENSUS TRACT N SUPERR•DISTRICT CODE BUSINESS PLAN FILED DAT ILE <br /> 2 J YES NO ' �7 <br /> A <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: ±1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST HI OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> q\V)J ORM A(3-2-BB) <br /> DATA PROCESSING COPY <br />