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STATE OF CALIFORNr7oC' WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> _ate- <br /> KFACILITYA'SITE, <br /> UNDERGROUND STORAGE TANK PROGRAMSITE INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE go <br /> MARK ONLY ❑ 1 NEW PERMIT Ej 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION1-1 7 PER ENTLY CLOSED SITE N <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 6 Z <br /> of <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMEk'� � � � CARE OF ADDRESS INFORMATION Job <br /> 5 M <br /> ADDRESS / l NEARESTCROSS ST <br /> R S/Batloodlrate AR;NERSHIP El STATE AGENCY <br /> o 5-re� ❑ CORPGRATION LOCAL AGENCY ❑ HOERALAGENCY <br /> E INDIVIDUAL 13COUNTRAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> TYPE OF BUSINESSA <br /> : 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if IN IAN EPA ID a <br /> E] 1 GAS STATION 0 3 FARM ❑ 5 OTHER RESERVATION orEl #of TAN / <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) # PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Lo✓e DLG/e 20 —8 3� 64 y 5x__L_� <br /> NIGHTS'. NAME(IAST,FIRSY PHONE#WITH AREA CODE NIGHTS: NAME(LASE FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS �f I I ✓Boa to i,dicafe ❑ PARTNERSHIP ❑ STATE-AGENCY ' <br /> / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME / STATES x ZIP CO; PHONE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box i.micate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE 21P CODE PHONE 0,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. ❑ 11. III. 11 <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> C.00DU ANT/Y# JURISDICTION N AGENCY# L K If of TANKS BI SITE <br /> I I O <br /> CURRENT LOCAL AGENCY F ID�#1 APPROVED BY N PHONE M WITH AREA CODE <br /> I'v <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> DE CENSUSTRACT# SUPERVISOR-DISTRI T CODE BUSINESSPLAN FILED DATE FILED <br /> 2 Z YES ❑ NO <br /> PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT* BY: ,4VV <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM rB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> 1,0-CA DATA PROCESSING COPY "� <br />