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yt�iuvrvn '�f <br /> STATE OF CALIFORN"I WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMA,R ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I,,,a, <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FAC$ TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1 i <br /> ADDRESS NEAREST CROSS STREET ✓Bw IDiMKBIe ❑ PA�LOX AGNIP ❑ STATEAFEDEU AGENCY <br /> ❑ CGR iIGN ❑ LGGAL-AGHIP D FEUERAGBO <br /> QUAL ❑ CGUNI)LAGENCf <br /> CITY NA STATE ZIP CODE SITE PHONE X,WITH AREA CODE <br /> CA Q <_32r0 1 (21 38'02 aX� <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID X _ X of TANi <br /> ❑ ❑ 5 OTHER I TRUST RESERVATION <br /> ESERRV LANDS <br /> ON or ❑ AT THIS SITE 0 <br /> ❑ 1 GAS STATION FARM ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA OO CARE OF ADDRESS INFORMATION <br /> Gam! <br /> MAILING or STREET AD HESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> jl5_,=yQ 411 Q.040VIDUAL ❑ COUNTY-AGENCY <br /> GI ME STAT ZIP E ( / PHONE X.WITH AREA CODE <br /> { T 8- L! <br /> 111. TANK OWNER INFORVATION & ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS v ✓Box tc indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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. ❑ It. 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 X JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE <br /> I I 1wv & <br /> CURRENT LOCAs AG T(!11 IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER CLQ/�-1/11 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> /� <br /> LOCATI$1LI CA(/�QDE CENSU� ACTX SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ DATE FILED <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT AAMMOODUNT FEE CODE RECEIPT C/L^ 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 /> '.�+ DATA PROCESSING COPY *-PA <br />