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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD •"''• <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SlT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �x <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION RT�7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 0 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME __ --�-' CARE OF ADDRESS INFORMATION <br /> 1 a/'4_YUO �d( C. <br /> ADDRESS NEAREST CROSS STREET ✓ ilduk ❑ PAATNERSYP ❑ STATE AGDO <br /> 3 X 5 ❑ INNDEDJ I 11 `O AMLY EOEMI.AGEMY <br /> CITY NAME ST CA ZIP CODE SITE-)q <br /> NEN,WITH AREA CODE <br /> TYPE OF BUSINESS. ❑ y DI IBUTOR ❑ d PROCESSOR ✓Box M INDIAN EPA IID N Sor(T 3 <br /> ❑ ICS <br /> 1 GAS STATION FARM ❑ 5OTHER RESERVATION <br /> LANDS or ❑ ///t x _ AT THIS SITE AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> `c ao9 a- a <br /> NI HTS: N E(LAST.FlRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME n CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,noicate ❑ PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> Stdime a S � T� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE AD "SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID Al N of TANKS of SITE <br /> 3 06 1 / = (:::) 1(�� <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE•WITH AREA CODE <br /> PERMITNU R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DIM11T CODE BUSINESS PLAN FILED ❑ DATEFILED <br /> YESNO <br /> CNEC • PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• 7 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 /> FORMA(3-2-88) - <br />