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STATE OF CALIFORNIP WATER RESOURCES CONTROIBOARD <br /> FORM `A': - UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 19 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) ul <br /> OD <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> / 2. �h /rC✓� <br /> ADDRESS NEAREST CROSS STREET ✓Bu wNxaie 0 PARTNERSHIP Ill FATE AGENCY <br /> OE{A. /T I ❑ CORPORATION ElLOCAL AGENCY 13RDERALAGENLY <br /> Cf Kms( ❑ INDMDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A,WITH AREA CODE <br /> Co(( Urt/+, CA ;?O'�— <br /> TYPE OF BUSINESS: 2 OISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID A <br /> [:] ❑ RRUSTYLANDS or ❑ #of HIS SITE 1 GAS STATION 3FARM SOTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(I-AST,FIRST) PHONE A WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(I-AST.FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> IIcji !'kNexIO I 6M nK vt <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> .I+1 1 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE A.WITH AREA CODE <br /> �.-Ic-I'O_N ( <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> [.l <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,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 /> APPLICANT'S NAME(PRINTED AL SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCYIN FACILITY ID R N of TANKS at SITE <br /> z 15us <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> NAS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED <br /> 23 3�S' YES ❑ NO ❑ /u v <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> � <br /> J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM AB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2C-BB) ` <br /> I I� I o- U 1 DATA PROCESSING COPY J\\ <br />