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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ge'"" T"` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM U " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FA /SITE �'A'•ae"'� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 P TLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 63 a) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> 0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> GRi ' w <br /> ADDRESS NEAREST CROSS STREET ✓Sm W'di*0 ❑ PMTNE WP ❑ STATE-AGENLY <br /> OI ❑ �u N ❑ R x`AceC <br /> INNMDU& ❑ ACY <br /> CITY NAME ` STATE ZIP CODESITE PHONE#WITH AREA CODE <br /> / CA SZ V <br /> Z.0 l//e <br /> TYPE OF BUSINESS: ❑!,pSffiBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION or #of TANK'# <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE#WITH AR A CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G rF �1 Ago � <br /> NIGHTS: NAME(LAST.FIRSIT) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME/�o /� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET AD/DRESS/l � ✓Box to ind,.M. 11 PARTNERSHIP 11STATE-AGENCYS L STOG�re N/ S7 11 Cl NDMORATION ❑ COUNTY AGENCY 11 LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> Lo ai Gfi� X77' <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to incioete ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I.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. ❑ 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION 0 AGENCY M FACILITY ID If #of TANKS at SITE <br /> 3 � <br /> 10 10 1 q � / 1 (0 1 1 ooar <br /> CURRENT LOCAL AGE Y F ILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> ny�FF 21d I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT S SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> YES NO ❑ <br /> CHECK# 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 INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />