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STATE OF CALIFORNij► WATER RESOURCES CONTROL BOARD <br />bun•K�"•, E` <br />FORM `A': <br />UNpERGROUND STORAGE TANK PROGRAM w `" <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �o <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <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) <br />FACILITY/SITE NAME <br />L7-L-Z.q ow, <br />LTi <br />CARE OF ADDRESS INFORMATION <br />mkfl� Prwok O <br />MAILM or STE.UT ADDRESS <br />Jo <br />�t' <br />ADDRESS / <br />NEAREST CROSS STREET✓ <br />r'yl-��/l�T�� <br />"'��t <br />Box tomdicale Cl PARTNER,SHIP ❑ STATE -AGENCY <br />El CORPORATION ❑ LOCAL -AGENCY El FEDERAL AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />// <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />SITE PHONE #, WITH AREA CODE <br />G(��T•) <br />CA <br />BUSINESS PLAN FILED <br />YES ❑ NO <br />DATE FILED <br />CHECK # <br />TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR <br />✓ Bax if INDIAN <br />EPA ID If <br />FEE CODE <br />RECEIPT # <br />1 GAS STATION E 3 FARM ❑ 5 OTHER <br />RESERVATION or <br />TRUST LANDS ❑ <br /># of TANK's <br />AT THIS SITE t <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) PHONE It WITH AREA CODE <br />DAYS. NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />W\jnl� <br />•1 <br />CARE OF ADDRESS INFORMATION <br />MAILM or STE.UT ADDRESS <br />Jo <br />�t' <br />O3O <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />CORPORATION 1:1LOCAL-AGENCY ElFEDERAL-AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />,_) <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />I]— <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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. ❑ if. ❑ III. ❑ <br />THIS FC <br />LOCAL At <br />3M HAS BEEN CQMPLETED UNDER PENALTY OF PERJURY, AND 1 U I HE 13E51 OF MY KNUWLEDGE, IS IHUE AND GC <br />LI NTS E ( INTED & SIGNATURE) DATE <br />2? -5--9I <br />iEN Y US00INLY <br />ERECT. <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # �4- <br />b <br /># of TANKS at SITE <br />I]— <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT # <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES ❑ NO <br />DATE FILED <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />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 />T DATA PROCESSING COPY <br />