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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 /> 4 COMPLETE THIS FORM FOR EACH FACILITY/SITE fo�y <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITENAME CARE OFADDR SS INFORMATION <br /> E iCE n/ <br /> ADDRESS NEAREST CROSS STREET ✓Box IN irdgre PAWNERGHIP ❑ BTpiEAGENCY N <br /> S r ❑ CORPOR TION OC L AGENC ❑ FEDER44AGEN <br /> Tt ❑ womb A ❑ COU"AGENCY <br /> (Q <br /> CITY NAME STATE ZIP CODE SITE PHONON.WITH AREA CODE N <br /> n1 CA 95ZD5 zoq <br /> TYPE OFBUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID x <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS or ❑ NON 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 /> 2oq �- y$3/ &O-AIC <br /> NIGHT NAME(LAST,FlR ) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> dd - o 47 <br /> II. PROPERTY 6WNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> N E � CARE OF ADDRESS INFORMATION <br /> E a <br /> MAILING or STREET ADDRESS ✓Box to,nd,cale ARTNERSHIP ❑ STATE-AGENCY <br /> A� -rte 11 CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> -3 �/ 1�� / 11 INDIVIDUAL. ❑ COUNTY-AGENCY <br /> STA <br /> CITY NAME TE ZIP CODE PHONE N,WITH AREA CODE <br /> /J C 95_2_Q 31 <br /> - <br /> III. TANK OWNER INFORMATION a ADDRESS — (MUST BF, COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> S c As <br /> MAILING or STREET ADDRESS ✓Box A.i,ft.le-'- ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION. ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. V 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 8,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY M FACILITY ID M a o1 TANKS at SITE <br /> ypi = = I in1"?, EEO 00 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> SEn✓/ �3/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE <br /> YES NO � 9 <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* 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 /> �i DATA PROCESSING COPY �� .� <br />