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STATE OF CALIFORNIA:" WATER RESOURCES CONTROL BOARD e <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV <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 t CARE OF ADDRESS INFORMATION <br /> erV <br /> ADDRESS NEAREST CROSS STREET ✓GO W 1*0 0 PARTNERSHIP 0 STATEAGENCY <br /> y� 0 WRPgGTION 0 LOCALAGERCY 0 FEDERAL <br /> # L7 Kr ❑ INDMDUAL ❑ Catsm AGBNCf <br /> CITY NAME (a. STATE ZIP CODE-T SITE PHONE p.WITH AREA CODE <br /> L\J CA moo( D <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> RESEATION <br /> ❑ 1 GAS STATION 3 FARM ❑5 OTHER TRUST LANDS or <br /> [:] ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRSTa, PHONE N WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> (a 04 �iG3-5 <br /> NIGHTS'. NAME(LAZT,FIRST) <br /> PHO# N WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 5 „__- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME' CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 3 T q k ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> U fee ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYNME STATE ZIPCOPE PHONE If,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to mcicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AG <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCOOE RHO# AR CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)BOX 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 UE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY N FACILITY ID a N of TANKS at SITE <br /> 39 = 00 11 007 goo <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> fil <br /> PERMIT 11 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED�,_ YES NO �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> 0. <br /> THIS FORM MUST BE ACCOMPANIED BjWf LEAST' -R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLFRR/S THIS IS A CHANGE OF SITE INFORMATION ONLY. `1 <br /> RM A(3-2-SS CA, <br /> u) ,� DATA PROCESSING COPY l( 1 ( ,w` <br /> �� 11\ <br />