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STATE OF CALIFORMPA WATER RESOURCES CONTRUL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM :Q, ' <br /> ° <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Yom ; 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) to <br /> FACILI SF AME CARE OF ADDRESS INFORMATION <br /> ADDRESS j r NEAREST CROSS STREET ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> 3 a i r Ca (( -dor nJ/ CC- / ❑�RPORATtON ❑ LOCALAGENCv ❑ FEDERAL-AGENCYray <br /> J LK INDIVIDUAL ❑ COUNTY-AGENCY (10 <br /> CITY NAME STATEZIP CODE SITE PHONE k,WITH AREA CODE <br /> L C 9 5O <br /> TYPE OF USINESS: F-12 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA ID n <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRT LANION DS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> scov; Ile 1�e01 ry 000 Ref & 54 <br /> NIGHTS: NAME(LST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 'su " <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ARCO Petro 1euw-_F1oo cf_- 6 <br /> MAILING or STREET ADDRESS yox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �` CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ,] ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE d,WITH AREA CODE <br /> L S w e I C A o I (900) 'fiQ 7 4f5 <br /> III. TANK OWNER INFQRMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME J CARE OF ADDRESS INFORMATION <br /> PtRCO Pp-tro ro cfS Ccu u <br /> MAILING or STREET ADDRESS y//ox to indicate ❑ 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 /> AL <br /> c a �a <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> rn <br /> ALJ I I I I I I = 10 3 1 --1) [61 01013 <br /> CURRENT LO L AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> fiC <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# I SUPE VISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 01 _X3 r �,0 4-1 / � YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 0 LY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />