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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> V i <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m Irk o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•ae5' <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ kPERWMI14TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 ( G..7 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C <br /> 4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �0 <br /> ADDRESS NEAREST CROSS STREET III= D PARTNERSHIP D STATEAGEN(F <br /> O W• (A &j CORPORATON D LOCALAGENCY D FEDERA-AGENCY <br /> INDIVIDUAL D COUNTY- <br /> AGENCY <br /> CITY NAME / STATE CZIP CODE 6 SITE PHONE N,WITH&REA S CODE <br /> A 16 _7/ <br /> TYPE OF BUSINESS: [72 DISTRIBUTOR F-14 PROCESSOR '/Box if INDIAN EPA ID ft S ^//v�M iof TANK'F li <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION O ❑ AT THIS SITE 7 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM++E��(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST FIRS I PHONE N WITH AREA CODE <br /> S� <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,F.EST) PHONE N WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEA / ^ /� CARE OF ADDRESS INFORMATION <br /> TµJ /V K 6 <br /> MAILING or STREET ADOP SS ✓Box to intlicate D PARTNERSHIP D STATE-AGENCY <br /> '1 /l /.' ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> L�� {/`� 11INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP COOD__ / PHONE p,WITH AREA CODE <br /> 9S(I/N/J6 �10940 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> M I p &A-L, 70if}"G7o 2 <br /> MAILING or STREET ArE� Q */Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> r�/ D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE�/V/ PHONE N,WITH AREA CODE <br /> 606-1 <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 FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION# AGENCY B FACILITY ID R M o1 TANKS N SITE <br /> [ E 10 0 D Do v <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRAT!jllkDATE <br /> LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 2 5-Q YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY \ <br /> `FORM A 13-2-SB) _- <br /> `WI `"' DATA PROCESSING COPY 1'• J <br />