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STATE OF CALIFORNIlr WATER RESOURCES CONTROL BOARD <br /> FORM 'A': _ ,m <br /> UNDERGROUND STORAGE TANK PROGRAM ® A,o <br /> SITE ( FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> l v c <br /> ADDRESS NEAREST CROSS STREET ❑✓Bww MrAk O PDX-�Y ❑ STATE AGENCY <br /> L� p/r4PEWGu ❑ coulmAGENCY <br /> ZIP CODE SITE PHONE R.WITH AREA CODE <br /> CITY NAME STATE <br /> Gs� CA <br /> DRIBUTOR ❑ /PROCESSOR EPA ID R <br /> TYPE OF BUSINESS: ✓Box if INDIAN Mol TANK'a <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS SFATION 3 FARM ❑5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE I WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C- <br /> MAILINGorSTREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> ed�vc��� Com' 9 � i -3✓0 <br /> Ill. TANK OWNER INFORMATION & iDDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WNICN ABOVE ADO MISS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. ❑ I. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION K AGENCY N —"FACILITY IDN N of TANKS N SITE <br /> 3 �{ .' ( a o a <br /> RENT LO ENCY FACILITY ID N APPROVED BY NAME PHONE R WITH AREA CODE <br /> E <br /> pE PERMIT APPROVAL GATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA R SUPERVISOR-0ISMMI T CODE BUSINESS PLAN❑FILED NO <br /> ❑ DATE FILED / <br /> CHECK R PERM,AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R BY: ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFIfO_R/NATION O1�LY, <br /> FORM A(3-2-88) <br /> 3`� C\ <br />