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."a"S`44NSi.�a,S.#L:""Iti�.^�yr.BW,.+ , -'o7•�'P.:i <br /> STATE OF CALIFORNIA- WAYE'lRESOURCES CONTROr•9OARD <br /> FORM 'A': 1� UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE \}} FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> r COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 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) to <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> C L <br /> ADDRESS. Y,• NEAREST CROSS STREET �✓ W Miwe 0 PARMENSHIP 0STATE-AGENCY N <br /> `'„I1 411tORPOMnON 0 LOGLAGI 0 FEDERAL AGENCY (J� <br /> O — 0 INDIVIDUAL 0 COUNTY AGENCY N <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA C152o 0 <br /> TYPE OF BUSINESS: DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ 0 NIS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L C2qq)41_Ae-7c)41 <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> COBE I <br /> MAILING or STREET ADDRESS �oindicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> �T7O ��./ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> TT I ofZN 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP C_qTnucanm CACOLODE PHONE#,WITH AREA CODE <br /> J�I <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> EiRG <br /> MAILING or STREET ADDRESS ✓ec.to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 12ppQ� CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> .S30 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> C <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. ❑ II. 5< Ill.❑ <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# FACILITY ID N Al of TANKS at SITE <br /> ZE FoTTE51 I d o I O <br /> CU PryryENT COCGCAL AOENC FACILITY IO# APPR VED BY NAME yr, PHONE N WITH AREA CODE <br /> "V 4 Z � l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE IT EX IMTION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1 2 3 SP /8 YES [:] NO <br /> CHECK# 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(32-BB) <br /> ._ DATA PROCESSING COPY <br />