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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': •: , . <br /> UNIJERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERWT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE `^��.o.�`^ N <br /> cl <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT EllfCHANGE OF INFORMATION ❑ 7 PERMAXy <br /> N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑B TEMPORARY SITE CLOSURE a) <br /> O <br /> I. FACILITY/SITE INFORMATION A ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> (�vt ar/Ps .S,�U�rtc <br /> ADDRESS NEAR-ST CROSS STREET ibrtle ❑ PARTNERSHIP O STATE AGENCY <br /> Loa-ASENCY ❑ RGER I.AGEN30S- N Y <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> _SvvC1ECA Asa of v�vY v�f-2G4: <br /> TYPE OF BUSINESS: ❑2gum"OR ❑F ✓Box BINDIAN EPA ID R NoI TANK'N <br /> ❑ 1 GAS STAT 3 FARMTITER TRUSTVLANOS ION Ix 1:1AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 5/C o1,rc Z_ l?Curl 0-0 - S'6S- (- (& 7 <br /> NIGHTS: NAME RAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S Gi r vL�e <br /> II. PROPERTY OWNER INFORMATION A ADDRESS — (MUST BE COMPLETED) <br /> NAME d/ CARE OF ADDRESS INFORMATION <br /> //�l7✓P T <br /> MAILING d STREET ADDRESS ✓Box to inEiwlo ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY O FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION 6 ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A60ve 7y <br /> MAILING a STREET ADDRESS ✓Box to Icc icNle ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT4 ZIP CODE PHONE N,WITH AREA CODE <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. II. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS K SITE <br /> `) 3 1 1 010 / / 1 O (9 1cp 1 0 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> Z�, /ROL 30 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRAACT -0I/ <br /> N SUPERVISORTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ©/ a3pD _fc;3 YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> Cog s/fid <br /> THIS FORM MUST BE ACCOMPANIERSY kT LUST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIO IS A CHANGE OF SITE INFORMATION <br /> FORM A(3-2-88) C <br /> DATA PROCESSING COPY <br />