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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A, <br /> FORM A. UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE y <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE L1 <br /> ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE loll <br /> AQ <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I W <br /> ADDRESS//� �� NEAREST CROSS STREET ✓Aorto irdiCdle ❑ PARTNERSHIP ❑ STATE lV <br /> 13 CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME !/ STATE ZIP CODE SITE PHON ,WITH AREA CODE <br /> /L/I /{` cA D 5 a o 2 5`6�- to l <br /> TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PR CESSOR -/Box if INDIAN EPA ID a �/� �,, <br /> ❑ 1 GAS STATION ❑3 FARM THER TRUST LANIDS ON or ❑ y I/1I y l..C1 It of HIS SITE AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE if WITH AREA CODE <br /> a, ao 9 <br /> NIGHTS'. NAME( T,FFIRST PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ' W <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> MAILING or S76EET ADDRESS ✓Box m,nd,cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME r e CARE OF ADDRESS INFORMATION <br /> MAILING or ST ET ADDRESS -/Box loinaicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> El INDIVIDUAL ❑ COUNTYAGENCY <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. ❑ 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 Of AGENCY# FACILITY ID If If of TANKS at SITE <br /> 2 1010 1 17a 8 000 3 <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROV BY AM PHONE#WITH AREA CODE <br /> .i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> C9 l 9 /a / 3 <br /> LOCATION CODE CENSUS TRACT# PERVISO DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3 , hu 1 3 a YES L] NO <br /> CNE # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> 1 FORM A(3-2-88) <br /> I fe�9 DATA PROCESSING COPY <br /> 0--1� <br />