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1 113-1 li NIL <br /> STATE OF CALIFORNL-, WATER RESOURCES CONTRGt BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> nD p <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> GCOMPLETE 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 qqy <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) s <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> lnj ltoLe s a.le 4 <br /> ADDRESS �u NEARES DROSS STREET ✓Bo kale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> x p S7' RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V 0� /`� 1 A � INDIVIDUAL ❑ COUNTY-AGENCY .� <br /> CITY NAMESTATCZIP COD��O SITE PH`N4) WITH AREA CODEW U <br /> h 6—r� A 7, loct <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 0CESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's n <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE (/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST FIRST PHONE#WITH AREA CODE DAYS: NA (LAST,FIRST) PHONE#WITH AREA CODE <br /> ofk <br /> NIGHT AME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE <br /> A, k1 <br /> II. PRO ERTY O NER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS VB ox t indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 'PI -0-4 <br /> �� PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> -v INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME � � STATE ZIP CODE PHONE#,WITH AREA CODE <br /> " <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME . /� 7 CARE OF ADDRESS INFORMATION <br /> MAILING or ST}/ T/ADDRESS/.� /'� ✓Box <br /> pt;dcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> v 1 V o (/ NDIVIDUALRATION ❑ COUNTY AGENCY El LOCAL-AGENCY oll <br /> ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> E PHONE#.WITH A EA JE,; <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. Tr 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) -7 ATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS <br /> /at�SITE <br /> 101 / 1/ �� V V <br /> —4 <br /> CURRENT LOCAL AS'aENCYFACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> VA L,/, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-D_ISjRICT CODE BUSINESS PLAN FILED DATE FILED <br /> (vJl YES NO Z7��/_! v <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 ONLY. <br /> ORM A(3-2-88) 7 <br /> i� DATA PROCESSING COPY kl <br />