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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE " <br /> MARK ONLY ❑ ( NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Qa, <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 0 eolu Co . ry <br /> ADDRESS tcNEAREST CROSS STREET `T ✓ 01,rd.N ClPARTNERSHIP ❑ STATE AGENCY CD <br /> L S!4 i S frLpeW COflPORATION Cl LOCAL AGENCf ❑ FEOEAALAGENCY <br /> CITY NAME ❑ INDIVIDUAL Ll COUNTY AGEN9 (M�� <br /> O / STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> K CA o105 (a29) ?V -p, p <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 P OCESSOA ✓Box if INDIAN EPA ID,EI <br /> ❑ 1 GAS STATION ❑ 3 FARM of TANK's <br /> �OTHEA TRUSTYLANDS G ❑ ��' •" AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a9 3- 8 <br /> NIGHTS NAME(I-AST.FIRS P NE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME San12 ctS Si te CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to od,c,.te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa YYl e R'S S! 6 <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ it. ❑ 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 If AGENCY N FACILITY ID N M of TANKS at SITE <br /> Ml = = I oa I l / d � OQo <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROYED YNAME PHONE M WITH AREA CODE <br /> fu O <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTI/Lj/"� 8 PERVISOR-D STRI T CODE BUSINESS PLAN FILED DATE FILED <br /> 0 / a3, O ll YES [:] NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ON . <br /> FORMA(3-2-88) <br /> �' DATA PROCESSING COPY <br />