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STATE OF CALIFORNIA <br />0 <br />0 <br />WATER RESOURCES CONTROL BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br />SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />/1 1 COMPLETE THIS FORM FOR EACH ACILITYfSITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IKS CHANGE OF INFORMATION <br />ONE ITEM❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NAME OF ADDRESS INFORMATION <br />fiRF.F 4nuse NmuT__�CARE <br />-- - $? n I --I-- <br />CITY NAME + { 1 <br />TYPE OF BUSINESS: �2 SDIISSTLRRIBUTOR ❑ 4 Pfl WR RESERVATION or ❑ <br />❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />besz� er ey,lo Caogr 3& --1,, <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />Sa f <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (I <br />NAME <br />NEAREST CROSS STREET <br />13rwf -1 t cL_. <br />❑ 7 <br />BOX iB wute <br />CLOSED SITE + 4 <br />•O <br />rrAi <br />pC� <br />PARTNERSHIP ❑ STATE -AGENCY Ij <br />LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />STATE ZIP CODE <br />JURISDICTION # <br />SITE PHONE H. WITH AREA CODE <br />D <br />Cao 33 `f --19a <br />CA <br />C6 <br />EPA ID #LAT <br />f TANK's <br />0cQ3 <br />THIS <br />ISS <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS'. NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />ST BE COMPLETED) <br />CARE OF ADDRESS INFORMATION <br />T( r to re s z [ e p- <br />MAILING or STREET ADDRESS ✓ Box to indicate Ll PARTNERSHIP ❑ STATE -AGENCY <br />C TM r , ❑ PIDUAL N ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />�) NDIVIDUAL ❑ COUNTY -AGENCY <br />STATE ZIP CODE PHONE #, Wvsw__�� <br />E <br />CITY NAME /rQ ^! LOE <br />Lp <br />; 11 <br />III. TANK OWNER (INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />CARE OF ADDRESS INFORMATION <br />NAME <br />MAILI�SEETorSS <br />CITY NAME <br />Box to indicate ❑ PARTNERSHIP <br />CORPORATION ❑ LOCAL -AGENCY <br />ininnrini AliFl COUNTY-AGENC <br />STATE I ZIP CODE <br />❑ STATF-AGENCY <br />❑ FEDERAL -AGENCY <br />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 NO <br />TIFICATIQN AND BILLING: I. Ll 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 Y SIGNATURE) <br />LOCAL AGENCY USE ONLY <br />DATE <br />COUNTY # <br />JURISDICTION # <br />AGENCY #FACILITMab!b <br /># of TANKS at SITE <br />Lj <br />C6 <br />0cQ3 <br />APPROVED BY NAME <br />PHONE # WITH AREA CODE <br />CURRENT LOCAL AGENCY <br />FACILITY ID # <br />PERMIT NUMBER <br />LOCATION CODE CENSUS THACT�I <br />C? q31, <br />CHEC # PERMIT AMOUNT <br />PERMIT APPROVAL DATE <br />SUPERVISOR -DISTRICT CODE <br />SURCHARGE AMOUNT <br />PERMIT EXPIRATION DATE <br />BUSINESS PLAN FILED DATE FILED <br />YES ❑ NO ❑ 1 , 13 <br />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 ONLY. <br />FORMA (Z -88) <br />.`� � , DATA PROCESSING COPY <br />