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STATE OF CALIFORMA WATER RESOURCES CONTROL BOARD '` <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ,� COMPLETE THIS FORM FOR EACH FACILITY/SITE `^�,.o�" ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANEN CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 112 CARE OF ADDRESS INFORMATION <br /> ADDRESS �/.J� / •/f.'-i NEAREST CROSS STREET ✓3m!0 r� 0 PANINERHIP ❑ STATE-AGENCY <br /> /3 ice. y S ElCDWOMTION 13 =A-AGM0 FEDISMKE O <br /> D IHDMOIIAL D copra AGENCI <br /> CITY NAME STATE 0 ZIPLOQ SipWITH AREA CODE <br /> /N-/V <br /> E�/yv,I CA <br /> TYPE OF BUSINESS. E:] 2 qjWrRIBUTOA ❑ 4PROCESSOR ✓Box if INDIAN EPA ID p <br /> ❑ 1 GAS STATIONEj_e3 FARM ❑ 5 OTHER RESETVATION oIf of lel) <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE if WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME , - CARE-1// D F ADDRESS INFORMATION <br /> w/S/ Tlxun, <br /> Rd,KcIfl, <br /> MAILING or STRET EADDRESS Box to indicate PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> B DAlf oy 1 D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME / q STATE ZIP CODE PHONE$1,WITH AREA CODE <br /> 9 5A <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE CCOMPLETED) <br /> NAME S A <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR MOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if.X <br /> If.❑ <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 R JURISDICTION R AGENCY R FACILITY ID R S of TANKS SI SITE " <br /> o 00 <br /> CURRENT LOC CI%I FACILITY ID A APPROVED BY NAME PHONE R WITH AREA CODE <br /> PERMIT NUYB PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 13 4 3 YES NO 9 / <br /> CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> THIS FORM MUST BEACC MPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS 15 A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) ` l✓ J( <br /> U <br />