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efP`iuOix '�f <br /> STATE OF CALIFORNIX► WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMA z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 <br /> f9lIi ORX�P <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) W <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A111V <br /> ADDRESS / NEAREST CROSS STREET biPsxlw ❑ PAFINERSHIP ❑ STATE- <br /> AGENCY <br /> 2 a CWPOAA ON ❑ GG AGFNC ❑ IDEPALAGBQ <br /> ❑ INGMWAL ❑ fAYJNTY-AGENCY <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CITY NAME / - T�// CA `� O <br /> TYPE OF BUSINESS 2 DIS UIOR 4 PROCESSOR I '//Box if INDIAN EPA ID N 3 M of TANK's <br /> ❑ ❑ RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAO PHONE N,W}TH AREA CODE DAYS. NAM ST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N/{WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME O�pw- n /�A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,rd cafe ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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: I. II. ❑ 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 N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE <br /> [m] =- 10 1-0 141= opo <br /> CURRENT LOCAL AGENCY F&CILITYAPPROVED BY NAME PHONE N WITH AREA CODE <br /> A <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CqE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z YES � NO <br /> CHECK M PERMIT AMOUNT BURC ARGE AMOUNT FEE CODE RECEIPT <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(32-88) <br /> DATA PROCESSING COPY <br />