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STATE OF CALIFORNA? WATER RESOURCES CONTROL BOARD <br /> FORM 'A': � 1 <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) � <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMA <br /> XTI <br /> 293 r Alla l " 4_4 <br /> AODRESS NEAREST CROSS STREET Aul ricak C PARTNERSHIP C STATE AGENCY <br /> 24 a C CORPORATION C LOCAL C FEDERAL <br /> Ck T C INDIVIDUAL C COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 265- 2 -y63 a�7 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #.f TANK'# <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c 20 6 423 171 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> si�we as r&m'-p_ <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> e u5 l <br /> MAILING or STREET ADDRESS V`Box to indicate C PARTNERSHIP ❑ STATE-AGENCY <br /> C CORPORATION C LOCALAGENCYC FEDERALAGENCY <br /> C INDIVIDUAL C COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME /x CARE OF ADDRESS INFORMATION <br /> 5b"" , 05 <br /> MAILING or STREET ADDRESS ✓Box toindicale C PARTNERSHIP C STATEAGENCY <br /> C CORPORATION ❑ LOCAL-AGENCY C FEDERALAGENCY <br /> C INDIVIDUAL C COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE 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 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN <br /> IN JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> II I <br /> '� = e7 H0101 <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE#WITH AREA CODE <br /> M iS' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TTRRACTIt SUPERVISOR-DISTRICT CODE BUSINESS <br /> SNFI <br /> LED NO ❑ DATE FILED <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 3 BY: <br /> THIB FORM MUST RE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION111, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> \ FORM A(3-2-68) <br /> 0 DATA PROCESSING COPY • <br />