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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD E, <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE aw� <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT ff�5�CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> IO <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N <br /> ADDRESS ` /'I NEAREST CROSS STREET ✓Bm 10 mut, ❑ PARTNE P 0 STATEAGENCY (D <br /> 0 CORPORATION -GENCY 0 FEOER4L-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 525435 Z2 f - KSD <br /> TYPE OF BUSINESS'. ❑ 2 DISTRI OR ❑ 4 PROCESSOR /Box If INDIAN <br /> or EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> AT TRIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c Sov-& 1098 est , o?'y<g — <br /> NIGHTS: NAME(LAA,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME ST,FIRST) PHONE#WITH AREA CODE <br /> b _ orb <br /> Ii. PROPERT OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADD SS ✓Box to intlicele ❑ P RSHIP 0 STATE-AGENCY <br /> Cl CORPORATION OCAL-AGENCY 0 FEDERAL-AGENCY <br /> • 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORM ION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale Cl 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 /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. 4111.❑ <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 It AGENCY# F ILITY ID# #of TANKS at SITE <br /> 39 = = 0 2- 3310 00 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY ME PHONE#WITH AREA CODE <br /> 3 <br /> \ - — -- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> EL <br /> CENSUS TRACT# SUPERVISOR-DISTRICT C09E BUSINESS PLAN FILED DATE FILED <br /> YESNOPERMIT AMOUNT SURCHARGE 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 V#/ <br />