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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '` °�• '. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " j <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'Anoaxv" <br /> MARK ONLY ❑ I NEW PERMITSI <br /> ❑3 RENEWAL PERMIT CHANGE OF INFORMATION Rn�7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) na <br /> N <br /> FACILITY/SITE/NJ�,ME CARE OF ADDRESS INFORMATION <br /> �1 Y12�Y11 d- I l�f 3t'n Ca <br /> mpolmll Cx r 1� j <br /> ADDRESS r NECEST GROSS <br /> �STREET ✓BPv 0 PAATNERWIP 0 STATE-AGENCY <br /> � 0.5141" Ljt_� PnTio13CY 0 FE <br /> l LGCSLAGENDEIw AGENCY j <br /> 0 INGMIwAL ❑ COUNTYAGENCY <br /> CITY NAME Fes, l STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA g520� 9 1 ((o(P I Siff <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID it <br /> ❑ 1 GASSTATION E]3 FARM ❑.6�OTHER TRUSTVLANDS or ❑ AT THIS <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) ----- PHgjJE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BEJCOMPLETED) <br /> NAME CARE OF ADDRESS D ESS INFORMATION <br /> CQn �Y\zIl Id ' CLc,-Y Cyw. a i <br /> MAILING or STREET ADORE ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> yL'�� � El <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> I I Q t I VINDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAME STAT ZI COD PHONE N.WITH AREA CODE <br /> Q L&) Q V L \ <br /> III. TANK OWNER INF RMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 11L f <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 j <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ If. 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 S JURISDICTION R AGENCY S FACILITY ID k R of TANKS at SITE <br /> ® I b I o I I I I I I;), I lololol <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> Con <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVI80R-DISTRICT CODE BUSINESS <br /> PLAN FILED GATE FILED <br /> a3� YES � NO aLl CC <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT ECODE RECEIPT* 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 /> FORM A(3-2-88) (Y, <br /> DATA PROCESSING COPY `e <br /> 1 <br />