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w Ya4 •+�a' '4 ">gF 7 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY1 NEW PERMIT F-1 3 RENEWALPERMIT [:] 5 CHANGE OF INFORMATION F__j 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ Z INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 01 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS14(0 A�jl"L4 NEAREST CROSS STREET ✓ oiMioah 0 PAUNEMIP 0 5'1ATFAGBICY <br /> — COAPORAiION 0 LOCAL-AGDO 0 FUMNLAGENCY <br /> INO1110UA1co <br /> 0 COMIY-AGEND <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA — 2cQ 3- 3"Y <br /> TYPE BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID x <br /> AS STATION ❑3 FARM ❑ 5 OTHER TRUST or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) �j�..q PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L�/ I J�3 <br /> NIG S: NAME( ,FIRST) pHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIG4S * <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I <br /> MAIUNG or STREET ADDRESS Be.✓ to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> C <br /> MAILING or STREET ADDRESS Z�✓Qo xtoindicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> IIYC0 PORAT10N 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> S 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE <br /> '� ZIP CODE PHONE#,WITH AREA CODE <br /> C I <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# 0o TANKS N SITE <br /> El = = I ci d I 1= 10 1 d O Wl <br /> CURRENT LOCAL AGENCY FACILITY ID# APP OVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT A ROYAL ATE PiRMITE (RATION DATE <br /> 24 <br /> LOCATION CODE CENSUS TRACT SUPER (BOR STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> oA 3 YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE hMOUNT FEE CODE RECEIPTp 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 /> FORMA 13-2-BPI <br /> �- DATA PROCESSING COPY <br />