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o <br /> STATE OF CALIFORNIA~ WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> IT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION LY CLOSED SITE N <br /> MARK ONLY ❑ 7 NEW PERM -J <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME I CARE OF ADDRESS INFORMATION <br /> �Li AM <br /> NEAREST CROSS STREET ✓CORPOMTO D LOCkAGEN D 3TATE-AAGD <br /> GENCY <br /> ADDRESS ' Q-1^� Cl IDNIDRAiION D LOUNT(AENCI ❑ FEDEiIP1-AGEIILY <br /> ❑ INDMWPL ❑ CWNtt-AGENGI' <br /> STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CITY NAME <br /> -T CA y,176 <br /> TYPE OF BUSINESS: 2 D IBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID p N of TANK' I <br /> \ ❑ 5 OTHER RESERVATI ON Dr ❑ AT THIS SITE <br /> ❑ 1 GAS STATION FARM ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WEAFF ARCOLE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> M I LW 1` ` <br /> NIGHTS: NAME)LAST, IRj PHONE p WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING Dr STREET ADDRESS ✓Box to iodicate D PARTNERSHIP D ATE AGENCY <br /> D CORPORATION ❑ LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to mccate 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 p.WITH ARF1,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. ❑ I. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION X AGENCY N FACILITY ID N N of TANKS M SITE <br /> [ O Cp (oI I o 10 ff <br /> CURRENT LOCA AGENCY FACILITY I" APPROVED BY NAME PHONE A WITH AREA CODE <br /> LCHECK <br /> MBER/,M! ',ra�1 PERMIT APPROVAL DATE PERM IT EXPIRATION DATE <br /> ON CODE CENSUS TRACT If SUPERVISOR-OISTRI CODE BUSINESS PLAN FILED NO <br /> ❑ DATE FILED (114 <br /> N PERMITAMOUNT SURCHARGE AAM NT FEE CODE RECEIPT It o/BY:- f <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> L/ DATA PROCESSING COPY �� <br />