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eE�'iui,i TMa <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY <br /> 7 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �I <br /> Ib <br /> i I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACIL}TY/SITE NAME CARE OF AgORESSINFORMATION <br /> L NA t <br /> ADORES NE EST CROSS STREET ✓6osto idkate PAWNERSIIP 0 STAT&AG D <br /> �VS �, ^ , ❑ CORPOUTION ❑ ,IIALAGENCY ❑ FEDEAALAGENLY r� <br /> ,Y/•lJJ ❑ INDIVIDUAL <br /> �G1UN1Y-AGENCY ; <br /> GIN NAM STATE ZIP COD SITE P ONE#,WITH AREA CODE Y,I <br /> CA `�' Zz" �! �'D o r� <br /> TYPE OF BUSINESS. p DISTRIBUTOR ❑ 4 ROCESSOR ✓Box it INDIAN EPA ID N# #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM �THER TRUSTVATION LANDSe E-1 !/" AT THIS SITE <br /> I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE yy WITH AREA CODE <br /> �v� D4 X33-33 $ .4 S/A <br /> NIGHT NAME( T,FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Sia <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> '31 <br /> MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK 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 /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY 1 <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. II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al AGENCY# FACILITY ID# Al of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED P_Z B/NA;l �/ PHONE Is WITH AREA CODE <br /> G/Jn��/lo- <br /> PERMIT NUMBER PERMIT APPROVAL DAT PER T EXPIRATION DATE <br /> /10 11 <br /> LOCATION CODE CENSUS TRACT# SUPER ISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 6 �7 YES NO � ,U Ir <br /> CHE M PERMIT AMOUNT SURCHARGIE 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 ONLY. �\ <br /> FORMA(3-2-88) \ ) <br /> DATA PROCESSING COPY �/ J <br />