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TATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �`""`' T` <br /> -'ORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION (� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 FERKONED LY CLOSED SITE ~ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� <br /> W <br /> FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) —I <br /> FACl/L�/SIT NAME CARE/ , <br /> ADDRESS INFORMATION <br /> ADDRESS / /1�)/'ryNfA(iE S T <br /> R REET ✓BQbiduPMN <br /> k 0 PMW ❑ STATE-AGBLI' <br /> D CORMTION 0 cr, cLOCA.LNiENCY gIX1l ENL? <br /> ✓(% ` Y D RavgYa D y <br /> GITY NAME STATE VI�CQDE� l/ O SITE P ONE N�ITH AF�Z <br /> A // � L ^JN 3 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4,R10CESSOR RESBox,f INDIAN <br /> ERVATION or EPA/ID//N <br /> r: WTANK's <br /> [:] A <br /> 1 GASSTATION ❑ 3 FARM ❑/ 5 OTHER TRUST LANDS ❑ C C'/ 04$0 / AT THIS SITE C' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> �FI1 /C ; , ���NoW��EE DAY5:�4��E(LAST,FIRST) (Ty1�NEN WITH AREA CODE <br /> NIGHT$:,NAME(LAST,FIRST) J PHONE N WITH AREA CODE NIGHTT(//�AME(LAST,FIRST) ..\i NE#WITH AREA CODE <br /> / LI � A <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> ft <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> � <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE AGENCY <br /> 0 CORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL U 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: I. el, N. ❑ 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 at SITE <br /> mI Oo I z 15Ll 13 1 1 0 lo I D <br /> CURRENT LOCAL AGENCYFACILITY 9/ IDN APPJU BYNAME /� PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE T[ LPERMITXPIRATON DATECENSUSTRACT# SUPERVISOR-DISTRICT CODES PLAN FILED DATE FILED <br /> YES NOPERMIT AMOUNT SURCHARGE AMOUNT FRECEIPT N 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 /> FORM A(3-2-88, , <br /> �- LOCAL AGENCY COPY <br />