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jo <br /> FtV <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ' COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ wu LOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE1412-23 Z <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS GNEAREST CROSS TREET 0 PARTNERSHIP 0 STATE AGENCY CED O'7C J q 0 CORPORATION 0 L AGENCY 0 FEDERAL AGENCY Q S ❑ INDWIOUALDNry AGENCY W <br /> CITY NAME STATE ZIP COOF SITE PHONE N.WITH AREA CODE N <br /> O <br /> CA Q <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑4 P5QEESSOR ✓Box if INDIAN EPA ID n <br /> It of TANKms <br /> ❑ I GASSTATION ❑7 FARM OTHER TRUSESETY <br /> LANDS ATIONor ❑ !V AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST( PHONE v WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE w WITH AREA CODE <br /> NIGHT$'. NAME(LAST,FIRST) PHONE N WITH AREA CODE) NIGHTS: NAME)LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFOR ATION <br /> MAILING or STREET ADDRESS ✓So-to ifbl e ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDGAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bw to amcete 0 PARTNERSHIP 0 STATE AGENCY ) <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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. ❑ 11. ❑ 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&SIGNATURE, DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION N AGENCY N FACILITY ID K N of TANKS at SITE <br /> � 001 357 � <br /> CURRENT LOC AGENCYILIT1 * APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NU BER (/ `IL/J/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION 3 CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED YES NO E] IV d O <br /> CHECK N PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT N it BY: <br /> THIS FORM MUST BE ACCOMPANIED BYATLEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> VU <br /> S <br />