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STATE OF CALIFOROA WATER RESOURCES CONTROL BOARD �y."au.iK;••.�f <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM w`2 ' <br /> Y Ism <br /> SiT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r ° �0 <br /> G' COMPLETE THIS FORM FOR EACH FACILITY/SITE `'OFORN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 z <br /> IQ <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Shatzonessu Cur uju S t- ry <br /> ADDRESS NREST CROSS STREET v ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CA <br /> /; RPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 5 PO C i 4 C /�- e r 1 w n c /`N i"NDIVIDUAL ❑ COUNTY-AGENCY C* <br /> CITY NAME STATE ZIP CODE SITE PH NE#,WITH AREA CODE <br /> S C,K CA ao Cao <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ TRUSRESETATION LANDSor ❑ No/V C AT THIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER <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 /> 1 'C, fi�ooZ"" Cao9 1.7� 55oy L, I - I I hevv►+�r coq X31-,)(,6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> cS 2-'1 '- <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,,4, . C Sha. Lk ti NeSSQ <br /> MAILING or STREET 05 ADDRE ✓Box to indicate El PARTNERSHIP 1-1STATE-AGENCY <br /> /� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST E ZIP CODE P ONE# WITH AREA CODE <br /> C0 I qsaolaoq)�1�F1- 0 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> of <br /> MAILING or STREET ADDRESS v ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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. X II. ❑ if.❑ <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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 16101l �I � � Gb3 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Shan <br /> PERMIT NUMBER Q PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CE�UB TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILE �� <br /> YES ❑ NO 7 <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />