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STATE OF CALIFORNIkC WATER RESOURCES CONTROeBOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE c, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �_� I C1 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1:17 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q' <br /> a: <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) } <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Drexel n Sti <br /> ADDRESS r NEAREST CROI�MS STREET ✓Am to iMxale ❑ PAAiNEASHIP ❑ S1AiE-AGENCY <br /> ` O ❑ NDI IV ILl CORP0AALION ❑ LO <br /> CAL AUNTY GENCY <br /> ❑ RDI AGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA Sz0 2 -9y6-Da33 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 # ppm / <br /> ❑ 7 GAS STATION ❑3 FARM V5 OTHER TRUSRESERYATION LANDS o ❑ ��Gb000 7 7 e+ / AT THIS SITE <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 /> 6 -oz <br /> NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> n NAME CARE OF ADDRESS INFORMATION <br /> Sikprff4 Wdlliws- <br /> MAILING or STREET sssAiiiDDRESS ✓Box to,Ddi ale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> g3$r7 ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODEO� PHONE p,WITH AREA CODE <br /> 54-1c kn&J <br /> 649 <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S�fhnC s <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 ANp'ILLiNG: I. ❑ II. 111.❑ <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(PRINTED8SIGNATURE) GATE <br /> ::�= <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# \ #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID� APPROVED BY NAME PHONE Jr WITH AREA CODE <br /> r <br /> PER ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED n <br /> 2 3 23 YES ❑ NO ❑ 0 70 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> C-f>< <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) -�- <br /> DATA PROCESSING COPY '^� <br />