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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM " / <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1--� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> F+ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S'. M�rlrn fa <br /> ADDRESSLb NEAREST CROSS STREET ✓WKIOMore ❑ PARTNERSHIP ❑ STATE AGENCY <br /> '2'7 //L WRPOM7IDN LOCALCl FEOERALAGENDY <br /> 11 INDIVIDUAL 1:1❑ COUNTY AGENCY <br /> / O 13 <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /i�L.//i( CA <br /> I 7=36 <br /> TYPE OF BUSINES ❑ p PSTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> t TANK's <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION orIf THIS SITE <br /> ❑ TRUST LANDS El AT <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(IAST,FIRST) PHONE WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S Af orllvelo <br /> MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O / / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYN STATE ZIP CODE11 PHONE p,WITH AREA CODE <br /> 19-2 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE(pCOMPLETED) <br /> NAM P CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W do,cate ❑ 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. ❑ if. 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 /> COUNTY# JURISDICTION Is AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3I I_// 1 <br /> CURRENT LOCAL AGENCY FACIIJTYJI7 M APPROVED BY NAME PHONE#WITH AREA CODE <br /> 04d— <br /> PERMIT NUMBER (Jf�////`J a�TL,A/'I//,PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC ION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 2 YES NO <br /> CHI K I PERMIT AMOUNT 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 INFORMA4ONLY. <br /> FORM A(3-2-88) 4� 0 <br /> DATA PROCESSING COPY* <br />