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STATE OF CALIFORNIH WATER RESOURCES CONTROL BOARD <br /> FORM `A': y� <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIT7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ia, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cyl FO Rt NNP <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 ®� O <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION <br /> r�w <br /> ADD ESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY �* <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA f52 <br /> TYPE OF SINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # TAT <br /> f TANK's <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDSor ❑ 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#WITH AREA CODE <br /> 912- �422 - �I� 3 -32Y 7- <br /> NIGHTS: NAME(LAST,FAST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,ORSTV PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF D R S INFORMATIO <br /> "�&5vm I/ Q�—d <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE/qZIP CODE � � PHONE#,WITH AREA CODE <br /> I C, <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) a7 <br /> NAME Ut CAR OFA DRESS INFO <br /> MAIL IN r STREET ADDPS§S ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> It ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN AM STATE � ZIP CODE PHO q,WITH ADE <br /> 0.2 <br /> IV. LEGAL NOTIFI TION AND BILLING ADDRESS C �_'�'`y <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 111. <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 /> CMI <br /> UNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I I I J EI I I I �� r� 1--i Eb <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY N E PHONE#WITH AREA CODE <br /> PER T NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE <br /> LOCATIIOON CODE CENSUS TRACT1 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G� <br /> 3 j YES ❑ NO ❑ a <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 11syl <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST' —MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) <br /> 4 DATA PROCESSING COPY <br /> 4 <br />