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i <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a. <br /> FORM `A': <br /> m�e <br /> UNDERGROUND STORAGE TA <br /> NK PROGRAM <br /> 0 <br /> SITE FACILITY/SITE INFORMATIONn <br /> a d/or PERMIT APPLICATION <br /> C ON <br /> 0 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / <br /> 1� <br /> j I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 6/c5d A/l7 ry <br /> ADDRESS NEAREST CRO STREET ✓Erwn°.i�rAwirankn 0 PARTNERSHIP 0 STATE-AGENCY <br /> 7xkc� Vn/C. C G, gBWUALION 0 LOLL -AGENCY ❑ fEDEPAL-AGEWY <br /> DNIDUPL ❑ CGWIY-AGENCY <br /> CIN NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> /4a 21121�7v CA 3 <br /> TYPE OF BUSINESS: F-12ISTRIBUTOR ❑4PROCESSOR ✓Boz N INDIAN EPA ION #1I TANK'. <br /> ❑ 1 GAS STATION 3 FARM NEA TRUSTYLANDS TION or ❑ QJ(/E� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LRST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST FIRST) /�'��� PHONE N WITH AREA CODE <br /> 3F 2 <br /> NIGHTS: NAME(LAST,FI ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,F ST) PHONE N WITH AREA E <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inoicae 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> I III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a 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 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. it. ❑ Ill.❑ <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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY a FACILITY ID Al M of TANKS at SITE <br /> ® U 10 <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE R WITH AREA CODE <br /> PERMIT NUMBER PERMITAPPROVALDAPERMIT EXPIRATION DATE <br /> i�V/Iy <br /> LOCATION CODE CENSUS TRACT M� SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> o�jvJl YES NO 2 <br /> CHECKN PERMITAMOUNT SURCHAR EAMOUNT FEE CODE RECEIPTF Bvf 11 <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) <br /> DATA PROCESSING COPY �..� <br />