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r _ C <br /> STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOARD _ I <br /> FORM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAMCAI <br /> `r <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 •. ° <br /> COMPLETE THIS FOAM FOR EAC FACILITY/SITE 1 � "�,. <br /> ORH <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION ❑ 7 pERMANE LV CLOSED SITE <br /> ❑2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION A ADDRESS - (MUST BE COMPLETED) .130 <br /> FACILITY/SITE NAME <br /> CARE PDORESSpyFFORMATION <br /> ADDRESS R / D 1 LSO <br /> 51 A NEAREST CROSS STREET ❑ PARTNEHSXIP r N <br /> rr ❑ FED RAGAGEN <br /> CORPORATION ❑ LOCAL ❑ FED RAL CITY NAME INONIOOAL ❑ COUNTY AGENCY <br /> -7k L/ STATE ZIP CODE SITE PHONE p,WITH AgEA COpE <br /> TYPE OF BUSINESS: ❑ cop DISTRIBUTOR A P ESSOR ✓ CA _ / _ Olf2 <br /> ❑ Box it EPA ID p O O <br /> ❑ T GAS STATION ❑3 FARM 5 OTHER RESERVATION or ❑ N of TANK'N <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCYCONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: Ng1.IE $T,FIRST( PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> S �94 �DZ PHONE N WITH AREA CODE <br /> NIGHTS: NA E(LAST,FIR ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIgSTI <br /> S / — 10j, PHONE p WITH AREA CODE <br /> 11. PROPERTY O NER INFORMATION A ADDRESSVV- (MU <br /> NAME ST BE COMPLETED) <br /> Q" I -` CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> m intllcele ❑ PARTNERSHIP ❑ STATEAGENCY <br /> CITY NAME <br /> LOCALAGENCYElFEDERAL AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CAS I q STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION A ADDRESS — (MUST BE COMPLETED) — <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STRE T ADDRESS 1— <br /> ✓ la intlicete ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCALAGENCY CI FEDERAL AGENCY <br /> CITY NAME INDIVIDUAL ❑ COUNTY-AGENCY <br /> 'C 8 STAT ZIP C E PHONE N WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS SZ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N� FACILITY ID N m � N o/TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY PHONE N WITH AREA CODE <br /> 1414? , <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT E%PIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE <br /> © SUEINEES PUN FILED DATE FILED <br /> YESNO E] <br /> CHECK N PERMIT AMOUNT BUNCH ROE AMOUNT <br />( FEF CODE RECEIPT N By. <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. <br /> FORMA(3-2-88) <br /> ce <br /> DATA PROCESSING COPY '/ S <br />