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OF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD " <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE AFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 101 5 CHANGE OF INFORMATION ❑ 7 FERMAN NTLY CLOSED SITE <br /> •Q <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> Ed_"_'qt1 d �Ae CARSan ,e <br /> ADDRESSh NEAREST CROSS STREET ✓Bm 0vlctle 0 PARTNERSHIP 0 STATE AGENCY <br /> yn/� 0 CORPORATION 0 LOCAL 0 FEOERALAGENCY <br /> 1- S M1// 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP DE /J CASITE PHONE a,WITH AREA CODE <br /> �7b <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PR SSOfl ✓ x if INDIAN EPA ID# TANKs <br /> RESERVATION or #of HIS SI <br /> ❑ I GAS STATION ❑ 3 FARM THEfl TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAVS: NAME(LAST,FIRST) P ONE y_WjT REA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> �d+A/a�d Gee '✓ 6 <br /> NIGHTS'. NAME(LAST,FIRST 7 PHONE If WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INF13RMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓BOA to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEd w z 4� _ / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ///:'//� ✓Box t0 indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL- <br /> AGENCY': <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ IL ❑ 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 /> COUNTY# JURISDICTION If AGENCY# FACILITY ID It #of TANKS at SITE <br /> ® = = 10O i (Q171 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE <br /> RR PF= <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO" CENSUS TRACT# SUPERV'17SOR-DISSTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> n <br /> L D Q YES Ej NOD fi' ZI <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: ��• <br /> V <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.A <br /> ORM • DATA PROCESSING COPY <br />