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STATE OF CALIFNo WATER RESOURCES CONTROBOARD r—o <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMo Z <br /> SITE 1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION la <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY T NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE h <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Off A <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 0000 <br /> FACILI /SIITTE NAME , ,, CARE ADDRESS INFORMATION <br /> ADD S NEAREST CROSS STREET ✓ Dirdi.te ❑ PARTNERSHIP ❑ STATE AGENCY <br /> CORPOMTION ❑ LOCALAGENCY Cl FEDERAL-AGENCY <br /> 0 INOMOUAL 0 COUNTY-AGENCY <br /> STATE ZIP COSITE PHONE#.WITH 7MCITUJJ CA SZVe6Y-Irll% <br /> NPE OF BUSINESS: 2 DISTflIBOTOR4 P OCESSOR ✓Box it INDIAN EPA ID N #of TANK's <br /> ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTYLANDS ESERATION O ❑ /v/4AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N ITH AREA CODE <br /> 6.kc ) ().Pin yw�/ a 36�S'l/7 0 �4 �/p <br /> NIGHTS: NAME(LAST, IRST) PHONE N WITH AREA CODE NIGHTS' AME(LAST,FIRST) PHONE N ITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA E owe 64t �-�,P CAR;0FpORESS INFORMATIONv 'MAI`IMG ar STREET ADDRESS to ind¢aTe ❑ PART SHIP ❑ STATE-AGENCY <br /> rlr �, �� / RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> {/ ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> �/� W) <br /> CITY NAME Dl STA ZIP (ZvI PITHAROCODE <br /> �// / <br /> CA 1 <br /> Ill. TANKKeAOWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME �- CARE OF ADDRESS INFORMATION <br /> v�o • <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE)t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. pl/ 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 /> 10 15 l k = da d <br /> CURRENT LOCAL AGENNJCY/F CILITY 10 N APPIV)V BY E PHONE#WITH AREA CODE <br /> (/G� <br /> PER NUMBER AP�O�L TE PERMIT EXPIRATION DATE <br /> 77 <br /> LOCATION CODE <br /> CPA CENSUS TRAC[T% SUPERVI80R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> b A ?iO YES � NO4ql <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <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 <br />