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STATE OF CALIFORNIA - WATER RESOURCES CONTROL BYARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE— FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> J_ ,Y COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILIAME CARE OF ADDRESS INFORMATION <br /> TY/SITE N <br /> ADDRESS ✓r V 5. NEAREST CROSS STREET ✓flmbidule D PARTNERSHIP D STATE-AGENCY <br /> ❑ COfBW701 D LWA AGDO D FEDEW AGENCY <br /> Cl INOMOUAL D COLAnY AGENCY <br /> CITY NAME STATE u ZIP CODE SITE 1 PHONE N,WITH AREA CODE <br /> J <br /> ii CA 36f- ,?0 <br /> TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N � , � � N of TANKS <br /> ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUSESETYLANDS ATIONof❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM (LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Iii Cao -306 <br /> NIGHTS: NAME(LAST, STI PHO E p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME % CARE OF ADDRESS INFORMATION <br /> MAILING or STR ET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <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 /> S S /' <br /> MAILING or STOIEET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION R AGENCY N FACIE B-I M of TANKS of SITE " <br /> 4 I > I cp O o d <br /> CURRENT LOCAL AGENCY FACILITY IDM aA"PROVED PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATEIRATION DATE <br /> LOCAT N CODE CENSUS TRACT♦ SUPERVISOR-DISLAN FILED D22dl <br /> '1 a� S NO �CHECK N PERMIT AMOUNT SURCHARGE AMORECEIPT N <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(3-2-811) - <br />