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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> Ga <br /> SITE / , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE •�°"-" <br /> C/ 1 A <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER EN LOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Im <br /> r <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓lialovdiera Cl PARTNERSHIP 0 STATE AGENCY <br /> [--11 F N �.2 n ;� ElYMMRKTIaN ElLOCALMENU 71FEDDIALAGENU <br /> ❑ INDIvmwL 0 MUNT(AGENU <br /> CITY NAME / I STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> J�Kd CA 524 Zo 9 V Yl 2 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 ROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION or If of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <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 /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: U ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION P AGENCY k FACILITY ID M M of TANKS at SITE <br /> 3 9 = = 1010 3 c 5 1 1 Dov 1 o <br /> CURRENT LOCAL AGENCY FACILITY ID Jr APPROVED BY NAME PHONE M WITH AREA CODE <br /> GiN <br /> PERMIT NUMBER PERMIT PPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT ON SUPERVISOR-DISTRICT CODE BUSINESS PLAFILED DATE FILED u <br /> 01 � 6 r/ O 32,3 YES ❑ NO /0- — / O <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: <br /> �+n <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LE?^(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S) "'ILESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> RMA(3-2-88) <br /> 11 \ --'10 ` DATA PROCESSING COPY �n \ <br />