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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE I"A' <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) m <br /> FACILITY ITE NAME CARE OK; <br /> F ADDRESS INFORMATION <br /> /Wjde)LoI <br /> ab <br /> ADDRESS NEAREST CROSS STREET –✓ iNcele ❑ PAIrtNMIP D STATEAGENCY <br /> �T SS ✓'l road � _ o INCNDWID,iION °o oo -AGENCY ❑ FmER4-AGFNCf <br /> CITY NAME 1 1 1 STATE Z CODE SITE PHONE IS WITH AREA CODE <br /> &Lv-\ CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID X X of TANK'F <br /> ❑ 1 GAS STATION [:] 3 FARM Efl <br /> RESERVATION <br /> or ❑ —J AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE IS WITH AREA CODE <br /> Ib (nenc_Qao`i gw.;io-1 I <br /> NIGHTS'. NA (LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRj�—� PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r c, r1 Seroi <br /> MAILING or ET ADDRESS indicate 0 PARTNERSHIP ❑ STATE AGENCY <br /> -XI CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> m wx 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IS,WITH AREA CODE <br /> qsd� 1 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.,STREEjADDRES indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> S YO 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STAT I ZIP/CODE PHONE X,WITH AREA CODE <br /> ✓1 1 <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. ❑ I. ❑ If. <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) /J DATE/ <br /> xy�l/ 3- 9-90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X AGENCY X FACILITY IDX 3((j�o X of TANKS at SITE <br /> U bl c3l of <br /> CURRENT LOCAL AGEMAY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DA FILED <br /> I a YES NO TO I <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X 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 /> �I1J <br /> FORM A(3-2-SS) <br /> \ L.�l DATA PROCESSING COPY <br />