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STATE OF CALIFORNO WATER RESOURCES CONTRO BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <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 ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' <br /> r <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓BgIJMFicale Cl PARTNERSHIP ❑ STAiEAGENCY N <br /> ADDRESS �� <br /> DRPORATIDN ❑ LOCAL AGENCY ❑ FEDERAL <br /> ❑ INDININ L ❑ COUNT AGENCY 'LNw <br /> GITyNAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE v, <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PA CESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION If of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM 1wl0THER TRUST LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST DEBT) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 23A"H (--- <br /> NIGHTS NAME(LAST,FIRST) I I- PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMPL) CARE OF ADDRESS INFORMATION <br /> _rff6A1 `�— <br /> MAILING VSTREETADDRESS ✓Box ti,odicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O ORPORALION 0 COUNTY AGENCY 0 LOCAL-AGENCY � F AL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> ).1 C 2a Y L/a AJ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFO ATION <br /> �E r T ,� £ <br /> MAILING or STREET ADDRESSndicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME• STATE ZIP CODE PHONE#,WITH AREA CODE <br /> JL— ZO <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. ❑ if. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED(� <br /> YES ❑ NO 6 <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 0 —5 <br />