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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ANENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> _ W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> & , I (ar 4ldA) <br /> ADDRESS /� NEAREST CROSS STREET ✓ bi'ArNe ❑ PABTNERRIP 0 STATE-gGENGY <br /> O LJRZ/V�/Y`�� /tQ CARPOMIION 1:110G1A(81IX ElfE�ENOL-AGDCY <br /> k ❑ INDMDGN ❑ cw4ry AGENC <br /> CITY NAMESTATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINE ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION a If of TANK's <br /> 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> - DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> _ o � y/r-z39-9126 Gl�� <br /> NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LIST FIRST) PHONE If WITH AREA CODE <br /> /J or/ fl. /2 U <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> d� <br /> MAILING or STREET ADDRESS R indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> CARPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ��( ❑ INDIVIDUAL CCOUNT'-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> � 3� <br /> 111. TANK OW R INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME� �/ CARE OF ADDRESS INFORMATION bel <br /> MAILING or STREET ADDRESS ✓ ox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> AA'7 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> I r ` 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIT NAM STATE U CODEPHONF N.WITH AREA CODE <br /> 9ySz I <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 /> COUNTY# III JURISDICTION If II AGENCY N FACILITY ID# Lp #of TANKS at SITE <br /> = f) o ( v D O <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 471 L-60 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVISOR-DIBTRICT CODE BUSINESS PLAN FRED DATE FILED <br /> res ❑ No ❑ 11161gq <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> r <br /> i <br />