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ATE OF CALIFORNA-r WATER RESOURCES CONTROCBOARD <br /> SRM A : <br /> UNDERGROUND STORAGE TANK PROGRAM �tl <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION B <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 P LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) ,© <br /> FACILITY/SITE NAME ' I CAREOFARESSINFORMATION <br /> 'l (g/F`IvJ <br /> N <br /> ADDRESSl Cs N ESTC OSSSTRREET ✓ tow w 11 PARTNERSHIP 13 STATE Amoy <br /> El LOCAL ❑ RODwLACDc00 <br /> ❑ WnAnaa ❑ MNACEN <br /> C <br /> CITY NAME J. STATE ZIPT.ODE_� � ITE PH EN,WITH AREA COD <br /> OGGC CA (Q/({SS 2 <br /> TYPE OF BUSINESS: ❑ 2 D19MIBUTOR ❑4 PROCESSOR ✓Box X INDIAN EPA ID# <br /> RESERVATION or N of TANK'# <br /> ❑ 1 GAS STATION ❑ 3 FARM F05 OTHER TRUST LANDS ❑ ATTHISSITE of <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENICY CONTACT PERSON(SECONDARY) <br /> DAY - NAME(LAST,FIRST) )PHONE It WITH AREA CODE DAYS: N �E1(LAST,FIRST) PHONE 6� LITH AREA CODE�! TV <br /> NIGHTS- NME(LAST, ST) PHON #WITH AREA CODE NIGHTS: AME(LAST,FIRST) PHONE ITH AREA CODE <br /> S A � <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE MOF INFORMATION <br /> MAILING r TREET ADORE ✓Bon to intliaate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 3a /- ] ❑ R' R' <br /> ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> lJ //�/ NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE THAREACODE <br /> 0 t' CA a <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFt,DQR INFORMATION <br /> MAILING orS REET D ✓Bay}tc intlicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> ❑�EORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �LTf INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CWEI PHOS* TH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS J <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. K 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION It AGENCY N FACILITY ID# k of TANKS at SITE <br /> 3 `1 Go 1 IiIIE00 1 o 11 <br /> CURRENT LOCAL AOENQY FACILITY IDM APPROVED BY NAME PRONE N WITH AREA CODE <br /> 2 <br /> PERMIT NUEMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D FILED <br /> 'ou YES NO �✓ <br /> CHECK# PERMIT AMOUNT SURC A G AMOUNT FEE CODE RECEIPT# B : <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> -W\ FORM A(3-2-8B) <br /> DATA PROCESSING COPY <br />