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STATE OF CALIFORN&� WATER RESOURCES CONTROL OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM uo <br /> SITE '� / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE -."'Jew <br /> MARK ONLY F] 1 NEW PERMIT F-15 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMAN Y CLOSED SITE I"A' <br /> ONE ONLY <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ~ <br /> A <br /> FACILITY/SIT NAME - CARE QVADDRESS INFORMATION <br /> ADDRESS NEA EST OR SSTREET ��✓§�biMia4 0 PAAINEIRIP 0 STATE AGDO <br /> LJ'COAPOAATION 0 LOX AGENCY 0 FEDERAL AGEN'O <br /> /� �• '�"A ❑ INDNIDUAL 0 CWNN AGENCY <br /> CITY NAME STATE ZIP CODE ITE PH NE ,WITH AREA�OD <br /> CA 95237 5; 7Z7-S} <br /> TYPE OF BUSINESS: F72 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or ,�^1 •01 TANK'1 <br /> ❑ 1 GAS STATION ❑ 3 FARM �5 OTHER TRUST LANDS ❑ A1A AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) HONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PH NE k WITH AREA CODE <br /> Zo% L A A <br /> NIGHTS: NAME(I-ASIT FIRST) PHONE#WITH AREA IDODE NIGHrTTO _NAME(LAST,FIRST) P_Oj{E p WITH AREA CODE <br /> S 4 8((A SM <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME / . CARE OF ADDRESS INFORMATION <br /> {l <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING&STREET ADDRESS ✓Box eradicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. 17TII. ❑ 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 R rJURISDICTION R AGENCY R C r. R of TANKS at SITE <br /> E�l I3 3 a <br /> CURRENT LOCAL AGENC M APPR ED BY N ME PHONE K WITH AREA CODE <br /> I L <br /> PERMIT NUMBER PERMIT AP ROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS Y 5 N FILED NO DAT IUD <br /> CHEC R PERMIT AMOUNT SURCH RGE MOUNT FEE CODE RECEIPT M B <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 <br /> FORM A(3-2-153) / <br /> I A / *41101" DATA PROCESS[ COPY �I( <br />