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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> sE�� <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��.oaA`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEIMAN71TLY CLOSED SITE IJ <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE d <br /> CIT <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) '4 <br /> CG <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1 NG <br /> ADDRESS NEAREST CROSS STREET ✓/6biGale ❑ PARINERSXIP yTA1EAGFNLY <br /> 3111 E onAr CMPtlU'ON 0 LOCUACEN,Y 0 ffDEVL4reo <br /> ❑ INDNDO& ❑ COUNn-nGENCY <br /> CITY NAME STATE (W CODE SITE PHONE M,WITH AREA CODE <br /> a k+o.-1 CA [So�05" z - s- 6y� <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ PROCESSOR ✓Boz A INDIAN EPA ID N <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or N of TANK'N <br /> ❑ TRUST LANDS ❑ AT THIS SITE01 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST,FIRST) P ONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> W-)ISO �r ao s <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 010 <br /> MAILINGor STIR ADDRESS ✓BOx to irldI.Me Cl PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �I INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> k C <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 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: 1. ❑ 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 N AGENCY R FACILITY ID M B of TANKS BI SITE <br /> D 11 15 17 13 1 10 1 0 10 <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE N WITH AREA CODE <br /> GRAYI,31 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PN FILED DATE FILED <br /> 01 <br /> .z3, g(� 2 PUN <br /> ❑ NO ❑ elfiilv <br /> CHEM PERMR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 /> / FORMA(3-2-013) <br /> DATA PROCESSING COPY .+ <br />