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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM , " o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> L COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ItT`S CHANGE OF INFORMATION 97 PLUU6KNTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> CJJ <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r� e S7 <br /> ADDRESS C/� NEAREST CROSS STREET ✓6pr.to irditdle ❑ P9R1Ac�A5NIP ❑ STATE AGENCY <br /> 2 1 se ✓p�- � ❑ AAPOA iION L lOGIUCAL AGFNC ❑ FEDEFALAGENCY <br /> C. V�'� J 1/� ❑ INDIVIDUAL CWNNAGFNCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> _T99Ic CA �3d 2L 3S <br /> TYPE OF BUSINESS ❑ p DISTRIBUTOR4 OC Ofl ✓BoxitiNDIAN EPA ID # <br /> 1 GAS STATION ❑ 3 FARM <br /> RESERVATION or X of TANK'S D <br /> ❑ 5 OTHEfl TRUST LANDS ❑ d ' ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME( ST,FIRST Q � M- PHONE`WITH AREA CODE . DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS'. NAME(LAST. IRST) J !•, PHONE p WITH f/AAREA`JCODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> D/ 5� _/ <br /> MAILING or STREET ADDRESS �y q `l ✓Box to indi ."' ❑ qn RTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑®/LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Prof S <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME lilt" 4"AA./'t, G D1S9 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate TNERSHIP ❑ STATE-AGENCY <br /> 1 Q ' U f ' •/ ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I% 1 ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITU NAME �1'A STATE_ ZIP GODE'�� PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND B LLING ADDRESS ✓PFJ /L <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> o <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> 23�V (� �/ YES NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BV: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) 46 <br /> DATA PROCESSING COPY • <br />