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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE Z FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE F+ <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> w <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ok Ni h fxJ10o I <br /> ADDRESS /� NEAR ST CROSS STREET ✓Bmbixxxt0 0 PARTNBSIIP 0 STATE AGENCY <br /> ,� glu�9 0 WRgMTION ❑ L2O -MENCI 0 FEDERAL AGENCY <br /> x.., CC4 YYL ❑ INJvi �NIY-AGBICY <br /> CITY NAME STATE ZIP CODEC SITE PHONE#,WITH AREA CODE <br /> -i CA g5aLIc7 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID 4 <br /> RESERVATION or - R of TANK'* <br /> E] I GASSTATION ❑3 FARM ❑-5'OTRER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED <br /> NAME CAREOFADDRESSINFORMATION <br /> Limi n l c(� �c o ISh,L f r'Ir-t-o-- u _ <br /> MAILINGor STREE [)Dll ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 1 Al L I,(� ❑ CORPORATION W11LO -AGENCY ❑ FEDERAL-AGENCY <br /> u l ❑ INDIVIDUAL OUNTY-AGENCY <br /> CITY NAME STAT Qti ZI�ODE PHONE#.WITH AREA CODE <br /> 'sa� U <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME rt ^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 11 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I.V. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. Ill. ❑ <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 R JURISDICTION R AGENCY R FACILITY IDR *of TANKS at SITE <br /> [m] D _I q( I b b I b 10 1 (L <br /> CURRENT LOCAL AGENCY FACILITY ID* APPROVED BY NAME PHONE*WITH AREA CODE <br /> pK rq f 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT*\ SUPERVISOR-0ITRICT CODE BUSINESS PLAN FILED DATE FILED"� [� <br /> a b I YES NO ,� 1 EY 0 <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 INFORMATI <br /> FORMA(3-2-88) <br /> V� DATA PROCESSING COPY <br />