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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD p si <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM LL wo <br /> SITEOACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Z-,tERII rlCLOSEDSITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> CO <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE OF A DRESS INFORMATION <br /> 421 C( /V <br /> ADDRESS N EST CROSS STREET_ - ✓Bodolnairele PARTNERSHIP 11 STATE AGENCY <br /> •/E�/4 ❑ COAPGAATION LOCAL-AGENp 11FEGEAPLAGENCY <br /> CC Lr4^�z�V ❑ INDIVIDUAL ❑ CGUNPYAGENCY <br /> CITY NAME STATE P CODE SITE PHOJE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINE S: F❑�/p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA <br /> `ID'# ,1 <br /> ❑ �/ ❑ TRUST VLANDS ATION or ❑ A, A AT THIS SITE GG <br /> 1 GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH gREA CODE DAYS: NAME(LAST.FIRST) PHON ITH AREA CODE <br /> SA A <br /> NIGHTS'. NAME( T FIRST, w ONE#WITH AREA CODE NIGHTS'. I�U.MLAST,FIRST) PHONEY ITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) dp N/ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAHUN(ErofVTREET ADDRESS ✓Box to indoate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY -❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indole ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> Cl 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 0 2- 5 3 6 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPRppVV E BY N� PHONE#WITH AREA CODE <br /> liPERMIT NUMBER PERMIT APPROVAL DATE `[�//`A(''' PEANUT EXPIRIATIO14 DATE <br /> LOCATION CODE CENSUS TRACT# SUPERV OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ZT. YES NO � l <br /> CHEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 4 THIS FORM MUST BE ACCOMPANIED BY AT LEASTTR MORE TANK PERMIT FORM 'B'APPLICATION(S), U} ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />