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OF <br /> I `11,pr A <br /> STA4TE OF CALIFORNI WATER RESOURCES CONTROL BOARD <br /> FORM `A': � <br /> UNDERGROUND STORAGE TANK PROGRAM =`� <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE �q l,FoRN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PE CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE � <br /> 1, FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N6 PA qI <br /> ADDRESS NEAREST CROSS ST���NDIVIDU <br /> e ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / H ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SI E PHONE#,WITH AREA CODE <br /> LU411 ro CA �I�3-G�.6 2. <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑a PROCESSOR -/Box if INDIAN EPA ID #RESER1114 <br /> % #of TANK's `3 <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or 1:1 'J // AT THIS SITE <br /> I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY COHIT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 9 a ej7, 6'0 jide!r I Me/ o g -3,6 <br /> NIGHTS: NAME(LAST,FIRSt) PHONE TWITH AREA CODE NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /�`' ❑ CORPORATION 1-1LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /'f V g— ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 5 �� CSA- szo d 20 _W/ <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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. [Pf <br /> III.❑ <br /> ""'PMIS 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 /> FPEN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 4 <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR- BTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> YES NO �PERMIT AMOUNT SURCHA E AMOUNT FEE CODE RECEIPT# BY* <br /> O <br /> 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAVOR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> \�_C\D DATA PROCESSING COPY <br />