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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 0 <br /> Ap COMPLETE THIS FORM FOR EAC FACILITY/SITE FH <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> r <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) `J <br /> CA <br /> FACILITY/SfTE NAME CARE OF ADDRESS INFORMATION <br /> 66Y"I- -7 ><I o T,4-rioN <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Bmb Nbceb ElPABMERSHIP ❑ FAM AGENCY <br /> wAY ' v5A D. Q INDryjWpf1TNW o `LOCAL AGAGE�NLT o 1E➢ER1L-AGE10 <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WIT REA CODE <br /> S�G�K°ToJJ CA al rlZb CZoa� - zql;�6 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box N INDIAN EPA ID N <br /> RESERVATION or ^ ,., k of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑.✓OTHER TRUST LANDS ❑ CAGOOOS35Doo AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ILAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> CDA/,9-,7XN .4Vr- (9oa) 4b&-1;t <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CSF-N��Z4L ,9NS�k tioN /NC - <br /> MAILINGorSTREEEMDDDRESS�/ ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P13 MD V DUAL13 CORPORATION El COUN Y AGENCY 11FEDERAL-AGENCY <br /> CITU NA014KI�41%1 SLA ZIP `�� PHONE N,WITH AREA CODE - <br /> TATE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) `'7/ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> i <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND RRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k AGENCY# F Li7TTD# - #or TANKS at SITE <br /> 3iI IZ S ° d1 1 111 <br /> CURRENT LOCAL AGENCY FACILITY APPROVED BV NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DIIITRICT CODE BUSINESS PLAN FILED DATE N ED <br /> C) 3�3 YES 0 NO E] - -9c) <br /> CHECK It <br /> PER <br /> AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> L / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST r`I OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) + / <br /> `� CA L DATA PROCESSING COPY <br />