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'�^'i'-mT`ITIYga+1##Y�'?IA'�MtIhAY1"'71F''h'K <br /> STATE OF CALIFORNIA WATER RESOURCESCONTROTBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> N 'I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWALPERMIT 5 GHANGEOF INFORMATION 7 PERMANEN OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE Q <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) GB <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS cj 1yG NEAREST CROSS STREET ✓Bar loiMrale 0 PARTO&W 0 STATE-AGENCY <br /> N• t7T r axtvu a Co °0 INDIVIDUAL O AGENCY ❑ EGEWL-AGENY <br /> CITY NAME xlNY1 �] STATE ZIP DE SITE PHONE#,WITH AREA CODE <br /> C//cy//V_/`�, CA Jro� %2 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR [:]4 PROCESSOR ✓Box#INDIAN EPA ID # #of TANK'N <br /> ��' RESERVATION or AT THIS SITE <br /> I GAS STATION 3 FARM [, THER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FI RST PHONE#WITH AREA CODE <br /> Cao 88 3Y11Sa/n;w (8-09 - 95 <br /> NIGHTS. NAME(LAS RST) I PHONE#WITH AFTEA CODE NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE <br /> IT Ar <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME IS CARE OF ADDRESS INFORMATION <br /> 0 J <br /> MAILINGor STREET AEVRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> a. CA s ao 1?,I <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 11 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WIT E <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> BE UBEfl FOR BOTH LEGAL NOT IF I 1 1114 AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST F MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> I <br /> COUNTY# JURISDICTION# AGENCY# FACILI #of TANKS H SITE <br /> CURRENT LOCCILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA)ZON CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> -3 011A CNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPTNO ❑ �BY.�'�� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FO M A(3-2-88) C_ ,\ <br /> �r DATA PROCESSING COPY ,� <br />