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"ef`W <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r ui� <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM =" .o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION off, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE — <br /> MARK ONLY ❑ 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P Y CLOSED SITE <br /> ONE ITEM � 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE S� <br /> CA) <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CA/RE� ^ADDRESS INFORMATION <br /> FACILITY/SITE NAME Z A"1 <br /> ADDRESS N EST RO SSTREET ✓Bo.mme#e D PARRNFASNIP D STATEAGENCY <br /> OD E. j ❑ COflPOMiION ❑ lou AAGEN IIEAAL <br /> L1V1 qJ - Cl INOIMI Tl ❑ .034 'ADO <br /> CITY NAME STATE 21Q�0SITE P ONE p.WITH AREA CODE <br /> LoD' CA <br /> 77 <br /> TYPE OF BUSINESS: 201STRI6tJ10R 4 CESSOR ✓eox if INDIAN EPA IDN #oI TANK) <br /> 5 OTHER RESERVATION Or ����a 1 L/4-7 AT THIS SITE (/V <br /> ❑ 1 GASSTATION ❑ 3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST,FIR i PHONE#WITH AREA GO DAYS'. NAME(LAST.FIRST) NE N WITH AREA CODE <br /> s 0 23 S%� A <br /> NIGHT NAME(LAST FIRST) PHONE p WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PH NEM WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to'maicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME STATE ZIPCODE PHONE If.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or ADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY <br /> D 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 80TH LEGAL NOTIFICATION AND BILLING: I. Il. El 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS M SITE <br /> CURRENT�LOCAL)AG�ENC�Y FACILITY ID# APP V D BY N ME PHONE#WITH AREA CODE <br /> L v/% 7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMfT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 -evG YES <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> \ I 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 /> v Ir DATA PROCESSING COPY <br />