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STATE OF CALIFORNN WATER RESOURCES CONTROBOARD <br /> SE�� lei <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE J n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMA YCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I <br /> FAIL /SITE NAME CO-L CARE OF CESS INFORMATION <br /> Ilk <br /> ADDRESS���� N T ROSS ST EET IoiMirale 0 PARTNERSHIP 0 STATE-AGENC! <br /> LTpJi/COflPOflAT0N ❑ LOCAL-AGENC! ❑ FEDER44AGENCY <br /> F NDNIDUAL 0 COUM-AGENCY <br /> CITY NE STATE ZIP CODE SITE PH NE#,WITH AREA <br /> CA S27d <br /> TVPEOF BUSINv9ESS: ❑ 2DISTRIBUTOR ❑4PROCESSOR ✓BO%If INDIAN EPA ID #of TANK ab <br /> ❑ iGASSTATION FARM ❑BOTHER RESERTRUSTYLANDS Or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHON #WITH AREA CODE DAYS:_N 1.1fj(LAST,FIRST) PHONE WITH AREA CODE <br /> S Y/+\ A <br /> NIGHTS'. E(LAST, IRST) P�NA ITH AREA CODE NIGHTS ]J�ME(LAST,FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF Q(7ESS INFORMATION <br /> MAILING ST EETADDRESS ✓ ox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> P4. <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM): PHONE#: H AREA CODE <br /> STFj7E ZIP <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) DC <br /> NAME CARE OFAqbRESS INFORMATION <br /> VIA <br /> MAIUN�r TgEET ADDRESS ✓ o to indicate 1:1 PARTNERSHIP C1STATE-AGENCY <br /> `J /npW CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT ZIP COD PHQyFTH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS l3 <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# #o1 TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> WI 2— <br /> P MIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA <br /> A ZZYES [-] NO 1O Gpw <br /> CHEC # PERMIT AMOUNT SURCNARG AMOUNT FEE CODE RECEIPT# Y: <br /> 1 THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> \w\ 0 DATA PROCESSING COPY is S_ <br />