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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> yE�` Thf <br /> 0 <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /Y COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM �NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 Z <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESSNEA EST CROSS STREET ✓Bm to merale Cl PARTNER IF 0 STATE-AGENCY <br /> 14 A ❑ CORKRAT1av 0 LOCAL 0 FEDERAL-AGENCY 00 <br /> l"61/ yc 1 r O r t El INDIVIDUAL. 0 COUNTY AGENCY -+A�7 <br /> CITY NAME STATE ZIP CODE I SITE PHONE N,WITH AREA CODE <br /> 9-fo C',IiiCA a o a 5� 5-63a3 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or Nof TANK'S <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ f ✓ `�� AT THIS SITE r �, <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> e e .za `f b 373 <br /> NIGHTS: NAME( ,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sa m ao - y75 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) i <br /> NAME S(' CARE OF ADDRESS INFORMATION <br /> o <br /> MAILING979 <br /> r STREET ADDRESS -/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> A7� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDE -AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAMEb STAB 'q' ZIP CODE O PHONE'p:WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> NAME CARE OF ADDRESS INFORMATION <br /> 41) Q0eA0y3I wrier <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL'Sr Ill.❑ <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 R JURISDICTION R AGENCY 41 FACILITY ID R R of TANKS H SITE <br /> © / l3 �f 000 / <br /> CURRENT LOCAL AGE CY FACILITY ID N APP O D I ME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT AIPPROVAL.DATE PERMIT EXPIRATION DATE <br /> R 3 O 0"-? <br /> LOCATION CODECENSUS TMCT('Y�.A SU RVISORAISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3 Q (J YESNO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. _ <br /> FORM A(3-2-813) - S <br /> 1 r DATA PROCESSING COPY <br />