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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z.'.""' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'F�"=`' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENT SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bm Niroone ❑ PAMNRSHIP ❑ STATEMENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDER41.-AGENCY <br /> SSO N. ❑ INDIVIDUAL ❑ COUNf AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE X,WITH AREA CODE <br /> ZZ/0 C-/C)61 CA <br /> TYPE OF BUSINESS. ❑ 2 DI TOR ❑ 4 PROCESSOR ✓Bo%ii INDIAN EPA ID X <br /> RESERVATION or // �((�� Aat T THIS I <br /> ❑ I GAS STATION FARM ❑ SOTHER TRUST LANDS ❑ U14-1— AT THIS SITE <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 /> S <br /> NIGHTS. NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDR SS ✓Box to kale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> p 11ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> { N• W INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE \ PHONE X,WITH AREA CODE <br /> 5' CIEp C �iJ� tC'21-.57,9L/ X <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 <br /> MAILING or STREET ADDRESS ✓Box dicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY k FACILITY ID R M o1 TANKS at SITE <br /> 3 w () 1 -31 <br /> © o 0 <br /> CURRENT LOCAL A0ERCY�FACILIf,I�D APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER K PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* CODE BUSINESS PLAN FILED DATE FILED ppp <br /> 3�, 3 -2aC YES NO � <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT 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 ONL . <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />