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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '"""'T' <br /> FORM `A': °��`�� �" <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE4 ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FACT /SITE 4i,ro��P 10 <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT S CHANGEOF INFORMATION ❑ 7 PERMANENTLY CLOSE&SHIEN <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE - � <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) cn <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> be lea <br /> ADDRESS NEAREST CROSS STREET <br /> ca ❑ PAAMERSHIP D STATE AGENCY✓ NRONION D LOCAL-AGEND' D FEGERALAGBI <br /> Y <br /> Q <br /> D INDIVIWAL D COUn AGENCY <br /> CITY NAME / STATE ZIP CODE SITE PHONE#,WITH AREA;; <br /> ✓n an7C «— CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4PROC ✓Box 0INDIAN EPA ID #PI TANKY <br /> ❑ 1 GAS STATION ❑3FARM THER TRUSTT LANESERVATIDS El❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> E <br /> ,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 4eh /PO nST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME LL CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME _ _ STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S CArV—e 0. S <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP COLE PHONE It.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: L 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID#_��) #of TANKS at SITE <br /> -3 D C) �S p C3 C) / <br /> CUR CAL AGENCY FACILITY IDM A ROVED BY NAME PHONE#WITH AREA CODE <br /> P MBER — RMIT APPROVAL DATE KPIRATION DATE <br /> LOCATION CODE CENSUS TRACTMSUPERVISOR- ICT CODE BUSINESS PUN FILED NO ❑ GATE FILED <br /> L/ <br /> CHECKS <br /> PERMITAMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT 15AAT(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-68) <br /> Valli DATA PROCESSING COPY <br />