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>r` <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> C <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) a o <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> d►Uek& S - T <br /> ADDRESS NEAREST CROSS STREET ✓B ical¢ ❑ PARTNERSHIP ❑ STATE AGENCY N <br /> �/ GRPORA¶ON ❑ LOCAL AGENCY ❑ FEDERALAGENCY 00 <br /> /O ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITU NAME STATE ZIP CODE ITE PHONE a.WITH AREA CODE <br /> CA IRS ) 33S -51/ <br /> TYPE OF BUSINESS ❑ p DISTR TOR ❑ 4 ERIC ✓Box if INDIAN EPA ID a q of TANK'a <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ATION C ❑ / W P—'L� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST PHONE a WITH AREA CODE <br /> e �b orb�l 8-� g L(� N I a - Z <br /> NIGHTS. NAME(LAST,FIRS PHONE a WITH AREA CODE NIGHTS'. NAME(L T,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> O <br /> MAILING or STREET ADDRESS ✓8 moicale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> SIeqll to ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME , IJ STATE ZIP CODE PHONE a,WITH AREA CODE <br /> lo 1I c5wo 1 !f3naelb <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ©cuen.,s Ti ( s <br /> MAILING STREET ADDRESS ✓Bo - kale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> I/p�( RPORATI ON ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> ! u/ ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> CA- -tb o 8 �2� <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. ❑ I. ❑ If. <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> mIoIff � a 1 id <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT MSUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED <br /> VES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 5 <br />