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STATE <br /> OF CALIFORNIA WATER RESOURCES CONTROL BOARD a. <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE4/4ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION''. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °�ti o `P C <br /> MARK ONLY ❑ t NEW PERMIT_ 3 RENEWAL PERMIT 12115'CHANGE OF INFORMATION 7 PERMANE TLY L l� <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �! Cr <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) 'p <br /> FACFUTY/SITE raF.•A - CARE OF ADDRESS INFORMATION <br /> .r AY-j9 <br /> ADDRESS NEAREST CROSS STREET ✓Box 10uhc B ❑ PART1094 ❑ STATE-AGENCY <br /> 1 :7 S11CDWMTQK ❑ LOCA' -AGENCY ❑ I'MEBAL-AGENCY <br /> 1 + ❑ G4pIVIO K ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE / SITE P,HOME N,WITH AREA CODE <br /> TYPE OF BUSINESS: E12 DISTRIBUT/R ❑i RPOS6 ✓Bwc H INOMN EPA lO N ESERVATION of r of TANIr� <br /> I GAS STATION 3 FARM TFEER TRUST LANDS ❑ <br /> JATTHISSITE <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 /> w,f C • <br /> NIGHTS: NAME(LAST,FIRST) PHONE-#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS �} ✓Box io indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 571 �- �su1J U <br /> III. TANK OWNER INFORMATION &ADDRESS--- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAt-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZFP CODE PHONE N,WITH AREA CODE <br /> IV, LEGAL NOTIFICATION AND BILLING ADDRESS I <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L El 11. n III.❑' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED IT.SIGNATURE) DATE 111 <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION X AGENCY I FACILITY ID M N of TANKS at SITE <br /> �&Ico <br /> -1 1 r� ZIE01 ol D E <br /> RENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> EZMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ATIO ODE CENSUS TRACT N SUPERVISO"I ICT CODE BUSINESS PLAN FILED DATE FILED�/ 7S Z YES NOCK N PERMFT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: - <br /> THIS FORM MUST BE ACCOMPANIED BY AT I.EAST 11)OR MORE TANK PERMIT:FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> FORM.A(3.2-88) <br /> J ��i J DATA PROCESSING COPY ;1 <br />