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STATE OF CALIFORNIA <br /> FORM `A': WATER RESOURCES CONTROL BOARD {sE ?z <br /> SITEUNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE' e 00 <br /> 00 <br /> MARK ONLY ❑ f NEw pERMIi �9" � <br /> ONE ITEM ❑ 3 RENEWAL PERMIT 5 CHANGE Of INFORMATION <br /> ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT PERMANENTLY CLOS D SITE 1-� <br /> I. FACILITY/SITE INFORMATION &ADDRESS— s TEMPORARY SITE CLOSURE w <br /> (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME Fy <br /> ASou CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> n - n f Q NEAREST CROSS STREET <br /> J �lo�ATlp ❑ PpAiNEGEN ❑ STATEAGENCY <br /> GEN <br /> CITY NAME �' �( � INDRPDUALIDN 0 CLOM OUNTY AGENCY ❑ FEDEAALAGENCY <br /> S � ❑ INDIVIGUAL ❑ CAUNiKAGENLY <br /> STATE ZIP ODE <br /> CA Sao SITE pHONEp.W AREA <br /> 1 y`61 <br /> TYPE OF Ru51rvES5. ❑p DISTRIBUTOR �❑q PROCESSOR ✓Box if INDIAN EPA `Y <br /> ❑ 11 GAS STATION ❑3 FARM E!7['OTHER RESERVATION or - <br /> TRUST LANDS ❑ �--- #of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> DAYS: E(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE p WITH AgEA CODE DAYS. NAME(LAST,FIRST) <br /> C.1 © 4 '(]� PHONE p WITH AREA CODE <br /> NIGHTS: ME(LAST FIRST) 1 I <br /> D ' PHONE#WITH AREA CODE NIGHTS'. NAME(LAST FIRST) <br /> �1 20c) �)G PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRE <br /> NAME SS — (MUST BE COMPLETED) <br /> E , - 1 l( ( I irijI CC) OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS T <br /> ,,, �'/,,V"�A�to indicate 0 PARTNERSHIP ❑ <br /> S ( T� CQj N CORPORATION 0 LOCAL- <br /> AGENCYSTATEAGENCYCITU NAME 0 INDIVIDUAL 0 COUNTY AGENCY 0 FEDERALAGENCYSia L 1� ST ZIP ODE <br /> l-( ��1 T� PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) d V <br /> NA <br /> OF-1RESSINFORMATION <br /> MAILING or STREET DDRESS <br /> O �n. ✓Box to intlicate ❑ PggTNER HIP <br /> `a.a t -)C, YI CORPORATION ❑ LOCAL-AGENCY 0 STATEAGENCYCITU NAME 0 INDIVIDUAL ❑ COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> S }p �T ST ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS aSdo� oZ0 y lea �� <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# T�AGENCY# FACILITY ID k <br /> #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NAME PHONE All WITH AREA CODE <br /> PERMIT NUMBER I PPEERLIIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTII SUPERVISOR-DISTRJCT CODE BUSINESS PLAN FILED <br /> pGZ 3 O o L4 17 v DATE FILED <br /> CHECK# PERMIT AMOUNT o YES In ❑ l- <br /> /�C ". .�. <br /> SURCHARGE AMOUNT FEE CODE <br /> RECEIPT In 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 0 <br /> FORMA FOR M <br /> DATA PROCESSING COPY <br /> 1 <br />