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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONo <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE F'+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) N <br /> CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS n, NEAREST CROSS STREET ✓Bwlo lnxi e ❑ PARINEI911P ATE-AGENC/ <br /> C/ ❑ CAgPo1UT10N ❑ LOCAL-AGENLY ❑ fEDEAAL AGENCY <br /> Cl INDIVIDDAI ❑ COUNTY AGEN(N <br /> CITU NAME STATE ZIP G P <br /> E SITE NE a WITH AREA CODE <br /> �1 CA 133 /s W7-z7 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR�o 4 PNWMR ✓Box if INDIAN EPA ID a <br /> RESERVATION or p K of TANK'X <br /> E] i GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ q ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS IjAME(LAST,FIRST)/ PHONE a WITH AREA <br /> CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> V/„ v — i <br /> NIGHTS: NAME LA511.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s x- <br /> MAILING or STREET ADRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> // [I CORPORATION ❑ LOCAL-AGENCY E3FEDERAL-AGENCY <br /> (/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME //cc STATE ZIP CODE -j �. PHONE#,WITH AREA CODE <br /> 116 � T-15-6 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIUNGor STRE ADDRESS / -/Box to Indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING INNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ If.Imo/ <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 N JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE <br /> = E= i5 3 <br /> CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENS"U�S TRACT X SUPERVISOR-DISTIIICT CODE BUSINESS PIAN FILED GATE FILED 4ONLY. <br /> YES � NOCHECK PERMIT AMOUNT SURCHAgOE AMOUNT FEE CODE RECEIPT aBY:THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATIO <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 1.94 <br />