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STATE OF CALIFORNIA WATER RESOURCES CONTRdt BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> RMANENTLY CLOSED SITE <br /> MARK ONLY El 1 NEW PERMIT E] 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION PE <br /> ONE ITEM 2INTERIM PERMIT q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE /'1 CA) <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �J O <br /> W <br /> FACILITY/SITE^NAME TT� CARE OF AD ESS INFORMATION co <br /> X1:1.n V-Q..) n <br /> c"ADDRESS A <br /> �1-_��rw� NEAREST CROSS STIFEEET ✓Barb vquP 0 PKINDWP 0 SIAIEAGDV <br /> +" — (Yt,QI\. C. ❑ INDM QCO�11014 ❑ COUNIYGBM.V ❑ FEDEW-AGUO <br /> CITY NAME 0� STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> TYPE Of BUSINESv.S CA O <br /> 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID N <br /> 1 GAS STATION 3 FARM RESERVATION or ❑ _ It of TANMF - <br /> TRUSTLANDS —�� ATTHISSME 0-� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( T,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Y l O (19(0-7 <br /> NIGHTS: 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 OFADDRES FORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> -jae In ,I -� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> IWKJ ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> OG_-L-- Cam Q U <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to intlicete ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 BOTH LEGAL NOTIFICATION AND BILLING: I. II. El III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST\MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY M FACILITY ID S M of TANKS at SITE <br /> MI = = I <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOrCQkE I CENSUS TRACT NSUPERVISOR-DISTRICT C1011 BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO C] C -.F <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 /> F RMA(3-2-88) <br /> `r DATA PROCESSING COPY �� <br />