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STATE OF CALIFORA WATER RESOURCES CONT BOARD <br /> efP iu��i� '�f <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM g °,o <br /> SITE /y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ©'PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (J 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) v <br /> FAC LITY/SITE NAME CARE OF ADDRESS IryFORMATION <br /> I t'Cwn Q�CLsc <br /> ADDRE NEARESTCROSS STREET ✓Ea N Wim ❑ PARTNERSHIP Cl STATEAGENCY <br /> .B'f,OAPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CIN NAME STATE Z;jQ CODE //''\\ SITE PHONE X,WITH AREA CODE <br /> CA �lJ 9 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID P <br /> RESERVATION or X of TANK' <br /> ❑ 1 GAS STATION [:]3 FARM �5 OTHER TRUST LANDS ElAT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) � ``�__ PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> VkJL— <br /> NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE X 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAZIP0OQE _ � — FPRONE WITH AREACOj,,, <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) 3/W <br /> NAME CARE OF ADDRESS INFORMATION <br /> cL� ly� <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCYCl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.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. ❑ 11. ��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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X AGENCY K FACILITY ID If #of TANKS at SITE <br /> ® 1 a0al OOO <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA COD <br /> m E tel-{ IR 15 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE <br /> C�OODDE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAM FILED <br /> V O]1, l(33 . YES ❑ NO ❑ (f C(jD <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYS <br /> FORM A(3-2-88) 0 0 <br /> DATA PROCESSING COPY 0 0 J <br />