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—. - �'7rT��V � r •r-.""v!7'+-r-�r�- M" '}i --%�-P'w i`ry.•�"-tom'-`�.t�11RI-i s•.r` '.�.n-.:'ti`T'MC!'-5���-b�=,���-. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': Ai <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z■ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C4(lFOR�P ■0 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLO ED SITE !V <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑8 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> eM940A) to <br /> ADDRESS NEAREST CROSS STREET ✓Box to Wicale El PARTNERSHIP 115TATE-AGENCY <br /> / VS M�Hley Ave, <br /> CORPORATION ClCAL <br /> LO -AGENCY IllFEDERAL-AGENCY <br /> 11INDIVIDUAL ❑ COUM-AGENCY <br /> CITY NAME: STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> _. <br /> CA j 0 - <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESEATION❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS o ❑ #of <br /> AT THIS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 20 t'315 -73 V1 <br /> NIGHTS: NA (LAST,F ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 11STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME _Z7 CARE OF ADDRESS INFORMATION <br /> 1h jar <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 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 5111. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> [NBER <br /> JURISDICTION# AGENCY# FACILITY 1 #of TANKS at SITE <br /> E[ H lo D <br /> ENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �Cf}L 15 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCENrS�US TRACTT�# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 -OO 3 YES ❑ NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST#R MORE TANK PERMIT FOR M `B"APPLICATION(S), UN THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />