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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE \c"`�•�"�"' <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Nr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -/ <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CAFE OF ADDRESS INFORMATION <br /> N <br /> ADIXiESS //1 NEAREST CROSS STREET ✓BDw RATID 0 PARTNERSEA 0 FSTATE EDERAGBILY 00 <br /> 0 FOflPoB91gN 0 IOGL AGENY FE➢EMI.AGENLY <br /> ❑ INUNIWAI ❑ CgMIYAGENCY CD <br /> CITY PIAMF—, /'1 STATE ZIP CODE SITE PHO p,WITH AREA CODE <br /> J` C CA �OrJ O <br /> TYPE OF BUSINESS: 2 DISTRIBUT R ❑4 PROCESSOR I ✓Box it INDIAN EVA lu A <br /> ❑ 1 GASSTATION ❑3 FARM ❑5 OTHER MUSTYIANDS ATINor ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME ILA T,FIRST) PHONE#WITH AREA CODE DAYS NAME ILA51,HEST) PHONE N WITH AREA CODE <br /> aa9 <br /> NIGHTS. NAME(LAST, RST) PH NE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME GAHE OF ADDHESS INFORMATION <br /> MAILING m STREET A HESS ✓Box tomicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 11.411 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE LIP CODE PHONE J!,WITH AREA CODE <br /> C/4 I 5 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓Box 1°=n ale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COLINTY-AGENCY <br /> CITY NAME STATE LIF CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. 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 A SIGNATURF) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION B AGENCY# FACILITY ID V B of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE F WITH AREA CODE <br /> Ln\ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT,y� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> y �3 > V v ��.._ YES NO — � / <br /> J CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: F1 <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. v t <br /> �T FORM A(3-2-SB) (,) <br /> V DATA PROCESSING COPY — \ <br />