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STATE OF CALIFORNIA WATER RESOURCES CONTROLB ARD s` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION *� <br /> COMPLETE THIS FORM FOR EACH FWCILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERM SEO SITE IV <br /> ONE ITEM ❑ 2INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE14 T <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS �r NEARE TCROSS STREz,nET ✓Bwlbidirate LI ❑ STATE AGENCf <br /> E `/.f ❑ CORPORATION ❑ LOCAL AGENCY ElFEDERAL AGENCY <br /> f ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAMELe) C�/+—n STATE ZIP O SITE PHONE X,WITH AREA CODE <br /> 4, 1 1 <br /> TYPE OF BUSINESS: ❑2 DISTR18UTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID X <br /> ❑ 1 GAS STATIONIf of TANK's <br /> ❑3 FARM OTHER TRUSTLANDS SERVATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA COLE <br /> NIGHTS: NAME fLAST,FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE X 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAVE CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME TATE ZIP CODE PHONE X.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOT-L GAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 X JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE <br /> [ ll�l = b 7 P'T71 16oo <br /> CURRENT LOCAL AGENCY F CILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBEI-C PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> (� LOCATION OE CENSUS TRACT,JL SUPERVISOR-DIS RICT CODE BUSINESSYES N FILED NO ❑ DATE FILED <br /> Vj\\ 'A �D a �v <br /> CXECKX PERMIT AMOUNT SURCHARGEA OUNT FEE CODE RECEIPTX BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)()R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. M <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 0 �� <br />