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STATE O CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Zile <br /> NEW PERMIT F—] 3 RENEWALPERMIT S CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cn <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME ���,,Ayy ...PO CARE OF ADDRESS INFORMATION <br /> .zuw;A_ <br /> ADDRESSqo, NEAREST CROSS STREET ✓Swo,00a, 0 PARTNERSHIP 0 STATE-AGBILY <br /> 0 0ORP011ATION 0 LOCALAGDO 0 FEGERAL#GENGY <br /> 7 Cl NDMDIIAL 0 CoUMAiGENLY <br /> CITY NAMESTATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> hoc K+0" CA 2(n - 6 -S <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID Al E of TANK'N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRTYLANDS ATION of ❑ <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LA ET,FIRST) PHONE N WITH AREA CODE <br /> a 1t" <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> .o. Ok __;0S(07 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Skd4zLa 5a 3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inoicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 ADORES$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 111. ❑ <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 N JURISDICTION R AGENCY N TV Do S of TANKS N SITE <br /> LI 3 <br /> ,pdkRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAM PHONkN AREA CODE <br /> D F �L <br /> PERM PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRR�ACT0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> 23.00 3Z� YES ❑ NO ❑ 0 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OE MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> i1 l FORM A(3-288) U <br />