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n.' <br /> STATE OF CALIFORI <br /> WATER RESOURCES CONT BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m r, �`v z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °^<iFOR- <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT NF CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE _j <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITEJ,NAME L 1_ - � CARE <br /> ^OF�AD'DRESS INFOR-M7ATI-ON- �, r <br /> S4bC l:-4T�T a j CLO-b <br /> ADDRESS NEAREST CROSS STREET <br /> I/Be bin@cele 0 PARTNERSHIP 0 STATE AGENCY <br /> Cl <br /> 3 a 3 s (V I ) CORPORATION 0 LOCAL ❑ FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 ODNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S f CA q ao A <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Bax it INDIAN EPA ID # <br /> ❑ 1 GAB STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION Dr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE IT WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 111. ❑ <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 N JURISDICTION N AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> 3q 0 1 1 1a 3 1010 10101 <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE#WITH AREA CODE <br /> SToc.k..3�. <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOLCODDE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED DATE FILED <br /> a .yu t�.( 6YES 0 NO# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IF BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(MORE TANK PERMIT FORM 'B'APPLICATION(S), UN HIS IS A CHANGE OF SITE INFORMATION ONLYYY5 <br /> ]CHECK <br /> RM A(3-2-SS) <br /> DATA PROCESSING COPY <br />