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STATE OF CALIFORNIA WATER RESOURCES CONTR&BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE `I _ <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 0— <br /> ADDRESS /GENL,cry`© NEAREST CROSS STREET ✓BPah&cMe 0 I'MITNERSHII' 0 STATE-AGENLY <br /> 0 OGL <br /> a o lA OWMTO 0 I - 0 FEDERAL.<00 <br /> G Cl INBMDALL 0 GONTY-AGENc( <br /> CITY NAME STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> C 2 CA b <br /> TYPE OF BUSINESS ❑ 2[1 RR %/Box if INDIAN EPA ID N If of TANK' <br /> RESERVATION or 1:1AT THIS SITE <br /> r] I GAS STATION ARM ER TRUST LANDS <br /> 40 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> if S 69io � 3 <br /> NIGHTS: NA (LAS .FIRST) ONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> S �� <br /> MAILING or STREET A KESS ✓Box to mdi.le 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,MIC.te 0 PARTNERSHIP ❑ STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ 11. ❑ 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 M AGENCY* FACILITY ID If A of TANKS N SITE <br /> 3 � 60 --//I '� g5 d : <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUB3TRACT• SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED NO ❑ DA )LED, {�JJ <br /> \ CHECK F PERMIT AMO NT SURCHARGE AMOUNT FEE CODE RECEIPT N (IFF „` <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(3-2-88) <br /> \N" vI / <br />