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STATE OF CALIFORNI0 WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V �' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> C._�_ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) OD <br /> W <br /> FACILI /SITE NA CARE OF ADDRESS INFORMATION <br /> >✓ G/a <br /> ADDRESS NEAREST CROSS STREET ✓Ba 11 to ln0icale C PARTNERSHIP C STATE AGENCY <br /> Oro V C INDIVIDUAL ION 11 C COUNTY AGENCY LAGENCY C FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA 205'" <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ PROCESSOR I/Box if INDIAN EPA ID p <br /> ❑ ESEF-11 GAS STATION 3 FARM OTHER TRUSTYATION LANDS o ❑ A of TANK'e <br /> AT THIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> 26`9 <br /> NIGHT$'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 209as-- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> ally aN l✓er s� rN� <br /> MAILING or STREET ADDRESS ! ✓Box to indicate C PARTNERSHIP Cl STATEAGENCY <br /> Ok ys C CORPORATION C LOCALAGENCYC FEDERALAGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> �� !A� e 75261 2eq,_ - 933vs <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box w m,cale C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION Cl LOCAL-AGENCY C FEDERALAGENCY <br /> C INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ It. Ill. ❑ <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 If AGENCY R FACILITY ID R k of TANKS at SITE <br /> dol t 17 1 a dao <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE <br /> C141- 20 77 <br /> PERMIT NUMBER LTL <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACCT# ICT CODE BUSINESS PLAN FILED DATEFILED ✓ <br /> 917 02.3 . () YES NO � /-2 <br /> CHECK M PERMIT AMOUNTNT FEE CODE RECEIPT M 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />