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STATE OF CALIFORN11 WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE c'l- FACILITY/SITE, INFORMATION and/or PE MIT APPLICATION ao <br /> COMPLETE THIS FORM FOR EACH F ILITY/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 /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) a <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓90XPindmale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �7y <br /> 7e,6/,- ti O IomouALoN O 10C AGENCY O Frfl�AL-AGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA 9r3za <br /> TYPE OF BUSINEGS. 2 DISTRIBUTOR 4 P ESSOR ✓B_it INDIAN EPA ID a <br /> 1 GAS STATION D 3 FARM 5 OTHER TRUGRULANDS ION or ❑ #oi TANK'# <br /> 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 /> �h .ems Zrr> 3� 7 z­`r -� y7- civ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> J <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to lnCicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Z CT SCO /Jve- ❑ CORPORATION ❑ LOCAL-AGENCY EDFEDERAL-AGENCY,/ ❑ INDIVIDUAL ❑ COUNTYAGENCYCITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 14 C/�- I s (,zv9�sa3-/ta <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> J/7J✓P <br /> MAILING or STREET ADDRESS ✓80x t.o0icate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTYAGENCYCIN NAME STATE ZIP CODE PHONE k,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. El II. 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# ACILITY ID# If of TANKS at SITE <br /> 7 1 q A / <br /> CURRENT LO A NCY FACILITY ID# APPROVED PHONE#WITH AREA CODE <br /> ejnRKjq <br /> PERMIT NUMB PERMIT APP ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT## SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> p v 3 ,)— YES NO 9/pa <br /> CNECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> BY: <br /> C <br /> -) THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORM TANK PERMIT FORM 'B'APPLICATION(S), UNLESS TH A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3288) I <br /> ��'� EYE - ( � �� DATA PROCESSING COPY ���1� <br />