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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s` ' <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> E <br /> SITFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> = CV COMPLETE THIS FORM FOR EACH FACILITY/SITE `^<,.o;'�`" <br /> MARK ONLY ❑ 1 NEW PERMIT 713 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANE TLY CLQI <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) O cI <br /> � <br /> FACILI7Y(SI-TE NE / C OF ADOR FORMATION <br /> ADDR <br /> ESS yn <br /> N ESTCROSS REET ✓QOXNJ16C2I2 0 PARTNERSHIP 0 STATE-AGENCY N <br /> G� 0 0 3 ® P� CORPORATION El IOCAL-AGE <br /> ❑ INGmowL IJ COUNTY AGENCY <br /> CITY NAM TATE ZIP CODE SITE PH E It ITH AREA CODE <br /> CA J( 3 <br /> TYPEOFBUSINESS: [:],,Z-DISTRIBUTOR ❑ 4 PROCESSOR I -/Box It INDIAN EPA ID NRESEi <br /> E] 1 GASSTATION 3 FARM E:] 5 OTHER TRUSTYLANDS of ❑ AT THIS SITE D D <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGIkNCY CONTACT PERSON(SECONDARY) <br /> YS. NAME QA T.FIRST) PHONE#WITH AREA CODE DAYS: ME(LAST,FIRST) pJl NE#WITH AREA CODE <br /> NIGHTS' NAME jLASA,FIRST) eHONE p WITH AREA CODE NIGAIAME(LAST,FIRST) PTANE#WITH AREA CODE <br /> r 4 A <br /> II. PROPERTY OW ER INFORMATIO &ADDRESS — (MUST BE COMPLETED) <br /> NAME_ A CARE O AD RESS INFORMATION <br /> MAILING STREET ADD ❑ Boxtoin4icate 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY F DERAL-AGENCY <br /> Ill INDIVIDUAL Cl COUNTY-AGENCY <br /> CII NAM STATE I ZIP ODE I PHONE�H AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CAREQ/A`/F RESS INFORMATION 7% ZaXI <br /> MAILING STREET ADDRESS ✓/8ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCYERA AGE CY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY E ST E ZIPS E PHONI AWITH 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. ❑ IL v 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> W I o DI `z-I Z +f IZ1 U 10 D <br /> lo I <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> M j4 C-^F/1 7-3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHI <br /> OCATIONCODE CENSUS TRACyTT � SUPERVISOR-DISTRICT CODE BUSINESS PLAN SLED F I/VI/U <br /> . 4�-/ l/ YES NO <br /> N PERMIT AMOUNT SUFICHARGI AMOUNT FEE CODE RECEIPTN 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 /> FORM A(3-2-88) r <br /> DATA PROCESSING COPY <br />