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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ;s`.. <br /> FORM `A': �.�I': -A <br /> UNDERGROUND STORAGE TANK PROGRAM = � " <br /> SITE E FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE _id <br /> r <br /> 'a IIFOPNI�' yF�/ <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT D<6HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CJS <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Pww2n le ❑ PARINMA P 0 SIATEAGENLY <br /> /S/S fl✓. i cs� O INorvl"POOI�uTiIGN O Eca r AGE <br /> r ❑ PmRI L AGENCY <br /> CIT'NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA 9S3 36 �?o <br /> TYPEOFBUSINESSy �3 dCJ <br /> ❑2 OISIRBUTOA ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> [jI GAS STATION ❑3 FARM ❑50THER TRUSTLANDS <br /> or ❑ #oITANK'N <br /> 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> NAME otCARE OF ADDRESS INFORMATION <br /> uCs� <br /> MAILING or STREET AbDRESS �✓ xx to inUicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> JzO - /D ST C1 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> /J?odL-sem G!4 9S.�S <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to inokate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III,❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY N FACILITY ID N N of TANKS at SITE <br /> -� 11q I = I CSO / /el X000 <br /> CURRENT LOCAL AGENCY FACILITY ID NAPPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMITA PROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE LBUSINESSPLAN FILED DATE FILEDES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CRECEIPT# BY: (� <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OPF Q E TANK PERMIT FORM 'B'APPLICATION(S), UNLES S IS A CHANGE OF SITE INFORMATION ONLY <br /> p ' FORMA(3-2-8e) <br /> `w /_�i DATA PROCESSING COPY <br />\ /1 <br />