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Y T <br /> STATE OF CALIFORNfpe WATER RESOURCES CONTROL BOARD s'`""' ' <br /> a A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'°OR"�' <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / 000 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) QO <br /> FACILITY/SITE NAME ` CARE OF ADDRESS INFORMATION <br /> lf=6141 Zl G4 oew.,v <br /> ADDRESS NEAREST CROSS STREET ✓fiorE✓m ❑ PAUNDIS9P ❑ STATE-ASDKY <br /> Cl 9 Fa iA-c 1, i%/ �- Cl IN o `Cam AGS ❑ FDX0. A3BXY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> c CA 95 aus" uA:-- <br /> TYPE OF BUSINESS: ❑ 2 DI IBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANK'# <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER <br /> RESERVATION or AT THIS SITE <br /> ❑ TflUST LANDS ❑ u�L D <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> /►9 a � ein 0i C-clL <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C4 <br /> f4, L4 Ic- <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,5 _ T <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> UlCCO�RRVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> See 1, <br /> MAILING or STREET ADDRESS J Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ fBRFORATION ❑ 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 /> 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 IDR N of TANKS at SITE <br /> [K9lI I I K= 10 In o a <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> LC 22 <br /> PERM) NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE TRA N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> i 3 a 3 YES [:] NO 7-Ac)-� <br /> CHECK# PERVRlAMQUli SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'Br APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 FORM A(3-2-53) �p ^/ <br /> ,Y I `� I'ILv DATA PROCESSING COPY —'S J <br /> V �/,y/� <br />