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V OF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> � w <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ P LY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE Iw,y <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) pNr <br /> FACILITY/SITE NAM CoI LAY '� -U/� ARE OF ADDRESS INFORMATION�T{ Z•7 IV <br /> ADDRESS NEAREST CRO STREET ✓ x ❑ iNEAHIP 11 STATE AGENCY <br /> AGEN 1:1 GER LAGEN <br /> Y <br /> COU <br /> 115— S l , Ie^ AGENCY <br /> CITY NAME STATE ZIP C S_ n SITE PHONE A,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR n 4 P ESWR ✓Box if INDIAN EPA ID# !/ <br /> k of TANK's <br /> ❑ 1 GAB STATION ❑3 FARM 5 OTHER RESERVATION or <br /> TRUST LANDS ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) I� PHONE N WITH AREA CODE DAYS. `N1AM� ,EE(LAST,FIRST) U PHONE#WITH AREA CODE <br /> J It km <br /> NIGHS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Pqn , - 67 u <br /> II. PROPERTY OWN R INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME sam, a7 � w����rya CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADORESS (/l V , • */Box to indicate ❑ P TNERSHIP ❑ STATE-AGENCY <br /> /j `! D CORPORATION CAL-AGENCY D FEDERAL-AGENCY <br /> (� �+ D INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STAT ZIPCODE � PHONE k,Wit H AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRES!� � ` C� I/Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION L PARTNERSHIP <br /> ❑ STATE-FEDERAL-AGENCY <br /> D INDIVIDUAL OUNTY-AGENCY <br /> CITY NAME / STATE,_, ZIPCODIE 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. ❑ II. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C RRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION a AGENCY# FACILITY ID If If of TANKS at SITE <br /> = = 101 b I i IT 010 � <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVIS�TRICT CODE 13USINES YPLAN❑FILED NO ❑ DATE FILED ' <br /> CNECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) 0 <br /> DATA PROCESSING COPY J <br />