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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE `'•Hoax`" in <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT EEr5 CHANGE OF INFORMATION 7 PERMAN ED SITE IV <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE IF bry <br /> r <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FAC LITY/SITE NAMECARE OF ADDRESS INFORMATION V <br /> ADD�/RYYESS NEAREST CROSS STREET ✓BwmirAceN ❑ PgRINEAGHP ❑ yTpiE.pGENCY <br /> O1 I vV J ❑ CORPORATION ❑ LOCALAGEN'CY ❑ FEDERAL AGENCY <br /> ❑ INDMWAL ❑ COUNIY-AGFNC/ <br /> CITY NAME_ r STAT^A ZI�C� SI7 p72 o ONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: VC 9 <br /> 2 DISTRIBUTOR ❑4 PROCESSOR '/Box it INDIAN EPA ID N <br /> 1 GAS STATION 0 3 FARM OTHER TRUSTVLANDS ATION or ❑ ATIf THIS KY <br /> AT THI831TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> f �Ob-SY(o <br /> NIGHTS: NAME(LAST,FI T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �W•wv <br /> MAILING o,STREET ADDRESS ✓BO.to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING STREET ADORE x to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> .E1J 4 (0�1 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CE_ PHONE tt.WITH AREA CODE <br /> V <br /> C <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L El 11. E If. <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 JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> 1 mol el a-H 1010 In <br /> CURRENT LWAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> ft ML& <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Is <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 9,-Y <br /> 1\,\ Is <br /> 3 . O (/ YES ❑ NO ❑ / D I r l D <br /> h\ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> ••J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESA THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br /> FORM A 13-2-88)_Vy� � DATA PROCESSING COPY Q\ <br />