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lw <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE / <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMNENTLY D SITE F-a <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 3 - <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) w <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> C) <br /> eye S'Oeo <br /> GL�L <br /> ADDRESS ll NEAREST CROSS STREET ✓3oq [] pAgBIE6BIIP ❑ STATE AGENCY <br /> I'dO . L (,� C� ❑ <br /> ON ❑ L«AL.AGFNCY ❑ FBXfI,L.AGRILY <br /> Gmlwa ❑ ra3Hn.AGErvcr <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Opp � CA 5 ;I-/a- !� <br /> TYPE OF BUSINESS: ❑2 IBUTOR Fl PROCESSOfl Box d INDIAN EPA ID N <br /> ❑ 1 GASSTATION 3 FARM 5 OTHER RE✓SERVATION of - //'' -- N of TANK'N <br /> ElTRUST LANDS [:iK OLAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S .T. <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 STREET ADDRESS ✓Box sate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CgAPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <j CARE OF ADDRESS INFORMATIONJ � Z <br /> MAILING or STREET ADDRESS ✓Box cafe ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PIRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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. ❑ 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 f JURISDICTION If AGENCY f FACILITY ID f If of TANKS at SITE <br /> l' D p 1 o 1 0 <br /> CURRENT LOCAL ENCY FACT ITY 19.{� APPROVED BY NAME PHONE N WITH AREA CODE <br /> (!Jl (jlf G/J�("/rl PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> LOCATION CODE CENSUS TRACT f SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE SLED <br /> 47 3 a_3 YES NO — <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 /> FORM A(3-2-8e) <br /> DATA PROCESSING COPY <br />