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o, <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 't'`"':: 'e <br /> A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE. , T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'°�"-"-'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION P RM TLY CLOSED$ITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY BITE CLOSURE O z <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1 <br /> FACILITY/SITE NAME � /� CARE OF ADDRESS INFORMATION <br /> /e 5 RTA- / (�jo <br /> ADDRESS NEAREST CROSS STREETwmiMi�ale Cl PARTNERSHIP El STATFAGENCv N <br /> (/y COWORATION 71LOCAL-AGENCY E3FEDERAL AGENCY -4 <br /> INOIVIWAL ❑ COUNTY-AGENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> AS'7dGlc'Ca� CA /S _St//— 5 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ OCESSOA I ✓BOX it INDIAN EPA ID a #of TANK'! <br /> ❑ ES <br /> 1 GASSTATION ❑ 3 FARM 5 OTHER TRUSYATION LANDS 0 ❑ l#_ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ­7r <br /> NIGHTS. NAME(LAST.F ST) HP ONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> vim uK <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS /�/ �'1-- /Q(� ox to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> VI✓ cc /// R 'K CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G / ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZI�COOJ: PHON�WIT RE DE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / P 71 ^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS C^/ 6 x to intlicale ClPARTNERSHIP ❑ STATE-AGENCY <br /> 4 A/Z P 7N1_ /OU ❑ NDIIVIDUAALION COUNTY AGENCY 11 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE ' PHONE N,WIT�REA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it.JZ 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# #of TANKS at SITE <br /> q 66 / Vs ogo d <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> K'—nA <br /> PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS # SUPERVISOR-DISTRICT E BUSINESS PLAIN FILED ❑EL <br /> ) <br /> 2, G YES NOCHECK# PERMIT AMOUNT v SURCHARGE MOUNT FEE CODE RECEIPT# <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(3-2-88) <br /> DATA PROCESSING COPY . <br /> i� <br />