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.ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD """ '` <br /> JRM A: UNDERGROUND STORAGE TANK PROGRAM ="� ro" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> GCOMPLETE THIS FORM FOR EACH FACILITY/SITE c""=°��� <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Ok — A1C/APs <br /> ADDRESS NEAREST CROSS STREET ✓Bow to lnoxf, 0 PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL AGEND <br /> S Ar. or 0 INDIVIEUAI ❑ COUNIY AGENCi <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 0 oN CA 206 <br /> TYPE OF BUSINESSp DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'N <br /> ❑ RESERVATION or AT THIS SITE y <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> F ✓cr sob' <br /> NIGHTS'. NAME ST,FIRST) PHONE#WITH AREA CODE NIGHTS'. AME(LAST.FIRS7) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> o�r9tiG7(1 f 5 4 <br /> MAILING or STREET ADD ESS ✓Box to In Nte 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> LOC/i I"I 5.Z �Zo*' 3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ���� CARE OF ADDRESS INFORMATION <br /> LL <br /> M1/�������� <br /> MAILING or STREET ADDRESS I/Bi to iiWicBte 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <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. ❑ II. V 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 /> / I / I 5 I 2 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> N E i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION)LODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> / Z so YES NO Q PO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(it OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY y <br /> uj \ -6- lJ <br />