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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONy <br /> ONE ITEM ❑ 7�PERMANENTLYCLOSED SITE LI <br /> ❑2 INTERIMPERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE qq <br /> •� <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) AWI^ <br /> FACILITYISITE NAME CARE OF ADDRESSNFORMATIO <br /> W <br /> C. <br /> ADDRESS 00 <br /> NEAREST CROSS STREET ✓ftYi aik 0 PMTWRSHP ❑ STATE AGENCY <br /> ❑ CORPORAfl N ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> CITY NAM INDNIDWL ❑ CMNTY-AGENCY <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> ST?pcTZ)14 �y <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID #CA 2pq — <br /> ❑ I GASSTATION 3 FARM 5 OTHER RESERVATION or ❑ If of TANKS TRUST LANDS <br /> 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) <br /> PHONE p WITH AREA CODE <br /> 1�LL 2C�q <br /> NIGHTS: NAME(LAST, RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST( PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> a o l I , Co mr-r- <br /> MAILING or STREET ADDRESS ✓Sox I.m,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> OIVIDUAL 13COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE p, ITH AREA CODE <br /> q Sa©3 (-2,DG LI -�3 - <br /> Ill. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING w STREET ADDRESt ✓BOK to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE p,WITH AAEA 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. k�L 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY MILITY IAC D M R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID R APPROVED B PHONE N WITH AREA CODE <br /> PER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS YPLAN FILED NO ❑ DATE FILE <br /> \b PERMIT AMOUNT SURCHARRGE AMOUNT FEE CODE RECEIPT# SBY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLM THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) <br /> V' .� 'N'6ATA PROCESSING COPY <br />