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STATE OF CALIFORNN WATER RESOURCES CONTROL BOARD <br /> FORM `A': W *� <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHF ILITY/SITE <br /> o_ <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT p AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE Qf ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET�,/� to IMIQIC ❑ RETREAD ❑ STATE AGENCY <br /> IV4 v l �� ✓� NDMPUAL� 13 LO <br /> ❑ CDU AGENM � FEDERAL AGENCY W <br /> CITY NAME <br /> STATE ZIP CO co <br /> J / 7 CA »� SITE PHONE WITH AREA C <br /> TYPE OF BUSINESS'. p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID p (// {J/ <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ #of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) ' C P,LO PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 7 n�tP�` 21 v 20 9-d y6- 1 <br /> NIGHTS: NAME(LAST,FIRST) _ PHONE N WITH AREA CODE NIGHTS: NAME(LAST IRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNE INFORMATION & ADDRESS — (MUST BE COMP TED) <br /> NAME CARE OF AD ESS INFORM TION <br /> 7n OA! lc�p, 7y.7 <br /> MAILING or STREET ADDRESS Ox toIntlicale ❑ PARTNERSHIP ❑ STATE- GENCY <br /> 2 A '! CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> 1T v El INDIVIDUAL F-1COUNTYAG ENCV <br /> CITY NAME / STATE ZIP CODEPHONE N.WITH AREA CODE <br /> s u/ U4 5 V <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME J� `^, ' CAWINDIVIDUAL <br /> REINFO�NIATIONL/ lJNCY <br /> MAILING or STREET ADDRES � m"0Z / ❑ PqRTNERSHIP `❑`'17STAAATT`Ef-AGORATION ❑ LOCAL-AGENCY ❑ FEDERAL-A❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA C <br /> S zN �h g/�Zo b _ <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: 1. F" If.Lv <br /> 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> v <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> S PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSU$TRACT#..., SUPERVISOR-DI�RICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES � NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM <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 />