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STATE OF CALIFORN6� WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIT9, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m, <br /> COMPLETE THIS FORM FOR EACH,FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Fr5 CHANGE OF INFORMATION ❑ 7 PERMAIENTI CLOSED SITE z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - �0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> CAD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION WIN <br /> C C p <br /> ADDRESS NEAREST CROSS STREET ✓Bmib TIO ClPARINEPGIIP ❑ STATE AGENCY V/ <br /> 0 ❑ CgRPDRAiIUN ❑ LOCAL-AGENp ❑ H .AGENCY <br /> (J rJ ❑ INGIVIDUQ ❑ CONTVAGENCY <br /> CITY NAME STATE IP CODE I SITE PHONE a WITH AREA CODE <br /> C CA 5a2-o Cao. 33 —11717 <br /> TYPE OF BUSINESS. F-] 2 DIST UiOR 4 PROCESSOR EPA ID a Box if INDIAN If Aof TAMP* <br /> RESE❑ 1 GASSTATION ARM ❑ 5 OTHER TRUSTYLAND$ATION or ❑ AT THIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(IAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> (es Caa 3 <br /> NIGHTS: AME LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> xS' ca�v>1� <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME , lCARE OF ADDRESS INFORMATION <br /> wG <br /> MAILING or STRE ADDRESS I ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ E ERAL-AGENCY <br /> 1 1-1INDIVIDUALCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE <br /> Lin cu C R q 5 Cao 33 fY <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET A DRESS ✓Box la indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ 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: 1. E] If. 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 N JURISDICTION* AGENCY R FACILITY *of TANKS at SITE <br /> �] DD � s <br /> MPERMIT <br /> ILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> a <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> S TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> . A 3 3 a O YES � NO / <br /> T AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X B <br /> ` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLM THIS IS A CHANGE OF SITE INFORMATION ONLY. _ <br /> ORM A(3-2-88) <br /> DATA PROCESSING COPY <br />