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STATE OF CALLFORNIft ' WATER RESOURCES CONTR BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM _ �o <br /> SITE f FACILITY/SITE, INFORMATION and or PERMIT APPLICATION <br /> C/ COMPLETE THIS FORM FOR EACH! CILITY/BETE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PE TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE CO PLETED) <br /> FACILITY/SITE NAME CARE 0 ADDRESS INFORMATION <br /> tis r tooM 6o <br /> ADDRESS / NEARS T CROSS STREET ✓Box I0ir&06 Cl 1`91711 6HIP 13 STATE-AGENCY <br /> / „_ � /J�� ❑ CAAPORITION Cl WATY-ADD ❑ FEDEMi-AGENCY <br /> (�+(/}yl� �vri/ ❑ INOIYIIWL Cl COUHfY-AGEN4Y � <br /> CITY NAME STATEZIP COD SITE PHONE N,WITH AREA CODE <br /> C ��� <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ff INDOX EPA tD N <br /> RESERVATION or A <br /> os <br /> TANK <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EME GENCY CONTACT PERSON(SECONDARY) <br /> f <br /> DAYS: NAME(LAIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 6 b eye " <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS- NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> i <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE C F ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> I11. TANK OWNER INFORMATION & ADDRESS - (MUST BEC MPLETED) <br /> NAME CARE IF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Bax to indicate © PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ WDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE j PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADIMESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ it. ❑ til. <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 j <br /> COUNTY M JURISDICTION B AGENCY N FACILITY IDS 0 of TANKS at SITE <br /> ?� f � G = � 101 012-LO-1 <br /> i <br /> CURRENT LOCALrNCY F CtLITY ID N APPROVED Y NAME PHONE 0 WITH AREA CODE <br /> M� 02 <br /> PERMIT NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �i <br /> .L YES ❑ NO 8i/6— 6 / <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT li AY: <br /> THIS FORM MUF BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMTT FORM ` 'APPLICATIOK(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> /FORM <br />