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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 4E" TSI <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 7 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE SED SITE <br /> ONE ITEM Yr2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE DJ Z <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A05 SS � NEAREST CROSS STREET ✓ mmtirele ❑ PARTNERSHIP ❑ STATE-AGDO <br /> T (� CORPORATDN ❑ LOGLAGENLY ❑ RDEAALAGENLY <br /> / St ❑ INDMDU ❑ WUNNAGENCY <br /> CITY NAME STATE ZI�OD SITE PHONE#.WITH AREA CODE <br /> Ca9 <br /> TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or ,�. //��I� '� #of TANK's <br /> ❑ 1 GASSTATION ❑3 FARM ❑5 OTHER TRUSTLANDS ❑ /�,w 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 /> tm M, ,Car q�8-P8! <br /> NIGHTS. NAME(LAST. RST) ONE#WITH AREA ODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e Ce- <br /> fl. <br /> a -P81 <br /> II. PROPERTY OVIMER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rgF M D S R SOG4{�S <br /> MAILING or STREET ADDRESSrpp7''' Oto intlicale 1:1 PARTNERSHIP 13STATE-AGENCY <br /> �a poeE owr El INDIVIDUAL <br /> 13 COUNTY-AGENCY <br /> 13 LOCALAGENCY ❑ FEOERAL-AGENCY <br /> CITY NAME STATE ZIP DE PHONE#,WITH AREA CODE <br /> L ( p9- yr O S I u-�C <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa4,"eas o e <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOGAL-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: 4 g, 11. ❑ III.❑ Ii <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> �. 0D 1 / l 600 `f <br /> CURRENTOAAAPPRODY NAME <br /> '"ONE WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPRQVAI,DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS T CT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> b YES NO <br /> \ CHECK# PERMIT AMOUNT SURCHAIRIE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ���\\\JJJVVVkkkORM A(3-2-88) <br /> \ `+'r DATA PROCESSING COPY �� /\ <br />