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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM t <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o, � ,o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�=I_•sR- <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S , <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> CARE Of ADDRESS INFORMATION <br /> LA e , k_ <br /> ADDRESS �C) 1J <br /> 1�J�/� NEAREST CROSS STREET ✓Bm.km.k ElPwNERSIIP 0 STATEAGENCY i <br /> O I ❑ COWOMTION ❑ LIKALAGEN(.Y ❑ FEDUALAGOO <br /> ❑ INGMWAL .2-CNNTYAGENLY <br /> CITY NAMEr STATE �°,C�D SITE PHONE N,WITH AREA CODE <br /> Locc -- CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Ni"Box it INDIAN EPA ID # <br /> RESERVATION or M of TANMF <br /> ❑ 1 GAS STATION ❑ 3 fAflM THER TRUST LANDS ❑ '�— AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> c ltien p 1 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME { CARE OF ADDRESS INFORMATION <br /> 01s1Yt <br /> MAILING or STREET ADDRESS ✓Be.to Indicate IllPARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION CILOCAL-AGENCYClFEDERAL-AGENCY <br /> L O Y GI ❑ INDIVIDUAL ,.2-'CCUUNTY-AGENCY <br /> CITY NAME STAT ZIP C E PHONE N,WITH AREA CODE <br /> Lo c� Q- a ol�)3� r <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q,D <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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 R JURISDICTION K AGENCY R FACILITY ID N K of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID IfLI 0�3 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UPIRATION DATE <br /> LOCATI C DE CENSUS TNACTN SUPERVISOIlj7Tpl CODE BUSINESS PLAN FILED ❑ DATE I <br /> 1 YES NO C <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ^ <br /> FORM A(3-2-88) l 1 <br /> DATA PROCESSING COPY <br />