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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM - ¢� o <br /> SITE /7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA Y/SITE <br /> MARK ONLY ❑ 1 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 —7 ' <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) / W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> sa S� W <br /> ADDRESS NEARESTCRO55 STREET 1/80111 ❑ PMTWJISHIP ❑ STATE AGENCY' <br /> o. ❑ CGIPDUTDN ❑ )GCA AGD LY 13FEGEPAI AGDI Y <br /> ❑ INDKDIN ❑ LGLHTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA '2e2 YEY - `/J 3/ <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 P SSOR '/Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION F-1 ❑3 FARM OTHER RESERVATION or ❑ N of TANK'N <br /> TRUSTLANDSAT THIS SITE 0 <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 /> �[ o 3�V jC tie <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> '61 /'Z' <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADORERS/ ✓ oiiWicale El PARTNERSHIP ❑ STATE-AGENCY <br /> 3�� ��P/h vn t 11 INLir D11 <br /> El 11 COUNTY AGENCY <br /> 11 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 15fE /7 �;9 95 2d!5-- o� - Y6 v - Y�3/ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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: L ❑ If. 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> __� o v y <br /> CURRENT LOCAL AGENCY FACILITY ID N I APPROVED BY NAME PHONE N WITH AREA CODE <br /> 31 <br /> PERMIT NUMBER PERMIT APPWOVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED I� <br /> 0/ y).> : ✓ 3,d3 1 VES ❑ NO /,2 —/ — <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> C�/7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST'I')R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-SS) <br /> V "'" DATA PROCESSING COPY w <br /> �J <br />