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STATE OF CALIFORN' WATER RESOURCES CONTR90BOARD <br /> ZE^` Jae <br /> FORM 'A': .. _ <br /> SITE /' UNDERGROUND STORAGE TANK PROGRAM <br /> J� FACILITY/SITE INFORMATION and/or PERMIT APPLICATION I z <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE I O <br /> oap` <br /> MARK ONLY O1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I-J► <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ <br /> 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 <br /> 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A <br /> ETi9 L <br /> ADDRESS <br /> NEAREST CROSS STREET ✓BOK loud ❑ PARTNERBMIP ❑ STATEAGENCY <br /> 7 C l ❑ C "' ❑ LDG`AGENC ❑ FEDERAL <br /> CITY NAME DYIDUgL ❑ COUNTY AGE <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Z_ t�evr CA 5PI 36 <br /> TYPE OF BUSINESS' ❑ p pl TOfl ❑4 PROCESSOR ✓Box if INDIAN EPa ID # C79 <br /> ❑ I GAS STATION 3 FARM ❑5 OTHER TRUSTYLANDS ATION or ❑ (��. #of TANK'e <br /> ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LACAR <br /> e e aG L)&-eST,FIRST) PHONE#WITH EA CODE DAYS: NAME(LASTIRST),F <br /> J PHONE k WITH AREA CODE <br /> NIGHTS: NAME TAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS. NAME(LAST.FIRST) <br /> PHONE q WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SlA /lvde�f <br /> MAILING or STREET DRESS ✓Box <br /> t cafe 11PARTNERSHIP <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> AGENCY <br /> CITY NAME INDIVIDUAL ❑ COUNTY- ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AAEA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> S' T <br /> CARE OF ADDRESS INFORMATION <br /> . <br /> MAILING or STREET ADDRESS ,�✓Ba intlicate PARTNERSHIP <br /> El C {dURPORATION ❑ LOTATE AGENCY <br /> CALAGENCY ❑ FEDERAL-AGENCY <br /> CIN NAME INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,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. 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION Al AGENCY# FACILITY ID k <br /> N of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME <br /> Q/ PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> / 3a 3 3aDATE <br /> 7FILED <br /> 3 YES � NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE / <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> 1JA—J\ FORMA(3-2.88) <br /> DATA PROCESSING COPY • <br />