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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': s <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 10 <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑6 CHANGE OF INFORMATION <br /> ONE ITEM ❑ T PERMANENTLY CLOSED SITE rV <br /> ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE j <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME all <br /> CARE OF ADDRESS INFORMATION <br /> c viNcF: <br /> ADDRESS <br /> �� NEAREST CROSS STREET ✓8mbuErsk ❑ PARTNERSHP ❑ srATFAmcy <br /> CITY NAME ❑ I�WIDX ❑1:1 NA Np ❑ EEOER4LAGENIX <br /> i A ._�� STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> TYPE OF BUSIN�ESSf❑( q ISTRISIfTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID aA )q3/- 3�/S-6 <br /> ❑ f GAS STATION 3 FARM ❑ S OTHER RESERVATION or #of TANK's / <br /> TRUSTLANDS ❑ AT THIS SITE l <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(RST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> .Q ,Q5o Cz� 366-NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> QRS <br /> MAILING or STREET ADDRESS ✓Box to iodic to ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> f ZZ 7 E•A�1T �6#'I/ �C+ ❑ ATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> PC— Z D 44Y <br /> MAILING or STREET ADDRESS ✓Box to inoicete ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> c Z,as r oq) '73l--_4d � <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 111.❑ II <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# JURISDICTION If AGENCY# FACILITY ID If If Of TANKS at SITE <br /> 3 0 0 3 lo o d <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED PATE(ILEO <br /> YES NO <br /> e5_1,5111 <br /> LT/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)00 ItgRE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. IFOR � .l <br /> (!A/*&� '�� DATA PROCESSING COPY \v\ <br /> _ WW 000��VII\ 14' Yp <br />