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77, --Jim- <br /> , S • r'lY,pilp.5�l'irl..,q.� .,v -. , —7 Wr"' ,-., -s' ],- <br /> STATE OF CALIFORNP WATER RESOURCES CONTROL BOARD <br /> FORM `A': _ o <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION CAI <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "1OR"`P <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT &KCHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED SITE <br /> ONE ITEM ❑2 INTERIMPERMIT ❑ 4 AMENDEOPERMIT ❑6 TEMPORARY SITE CLOSURE <br /> IC <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 0. V/ CARE OF ADDRESS INFORMATION <br /> �jTz" Ol rOY✓ N <br /> ADDRESS NEAREST CROSS STREET ✓BN to ir#icate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> `p ❑"WA ON ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> i se. (DUAL ❑ COUNTY-AGENCY V 1 <br /> CITY NAME STATE ZIP CODE L SITE PH NE It,WITH AREA CODE W <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4/PROCESSOR ✓Boz if INDIAN EPA ID # #of TANK's <br /> E] t GAB STATION ❑ 3 FARM Li.��IHER TRUSTYLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> lm .roy 6Ad -5/Z3 <br /> NIGHTS: NAME(LAST,f IR8T) PHONE#WITH AREA CODE NIGHTS: NAME(IAST,F ST) PHONE,WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to intlicare ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYY##a JURISDICTION M AGENCY# FACILITY <br /> 'I'D)# r �1 #of TANKS at <br /> SITE <br /> CURRENT LO AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> s 3h <br /> PERMIT NUMBER PERMITAPPROVAL DA TE, PERMIT EXPIRATION DATE <br /> [CHLECK# <br /> CENSUS TRACT# SUPERVISOR/-/DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> / YES E] NO � <br /> PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: , <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 /> DATA PROCESSING COPY <br />