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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �y�Pt pF1'hF <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH CILITY/SITE C4�,FpRNP 1 <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SLQ5LQ SITE Li <br /> ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> c - -. - S"rte <br /> ADDRESS NEAREST CROSS STREET ✓ indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 531: <T �`� `h�Cr ❑ INDIkdl VIDUAL GN 0 LOCAL-AGENCY❑ COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> cr/-L .7 CA 9.5 00 Jori -/Y3- (�3'r� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 YACESSOR ✓Box if INDIAN EPA ID # #of TANK't <br /> RESERVATION or <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ G C< �� (`��U AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> L o, O Y3-6 SGr r.1." <br /> NIGHTS: NAME( ST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> s S C! <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> I' CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (f 0 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME fSTATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L/ <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> EVCORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I/ <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. ❑ If. le/ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> o C? <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> S -'!2-3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAACtT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 -, J 3- 3 YES � NO /14;1 <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 ONL <br /> S_ <br /> .j <br /> A(3-2-88) <br /> DATA PROCESSING COPY <br />