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r.x,41"�'��• .� K` ry(�`e[':6 '}P°e•'pCMFl7� "ri�� 'l.. �_F.-F• .v.- ..- .rF � .. --, •- r . -- . - • <br /> I <br /> STATE OF CALIFORNIN WATER RESOURCES CONTROL BOARD <br /> FORM `A': �A <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SLTE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONrFa aNR. <br /> A COMPLETE THIS FORM FOR EACH F 0LITY/SITE A4 <br /> ciP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE �j <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE •C <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) Chi <br /> FACILITY/SIPS NAME CARE OF ADDRESS INFORMATION <br /> psi <br /> ADDRESS ]NEARlESTCR0S]SSTREELT _'/ b indicate ❑ PARTNERSHIP ❑ STATE-AGENCY'CORPORATIGN ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY❑ INDNIOUAL ❑ COUNTY-AGENCYCITY NAME ZISITE PHONE#,WITH AREA CODE <br /> GEC ,. a ao 31—G 5 pG <br /> TYPE OF BUSINESS- ❑ 2'DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVA❑ i GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS or ❑ N of HIS SITANICTE IAT THIS SITE <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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER.INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f or Si bell- boa AHn : S . LI Ne [So,^, <br /> MAILING or REST ADDRESS ✓Box 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11 S <br /> 11 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL ❑ COUNTY-AGENCY " <br /> CITY NAME +�+ 4 STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNEWIN FORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION ' <br /> s <br /> MAILING or;TRE ADDRESS F Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ II. til, ❑ <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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> x <br /> EPIER <br /> JURISDICTION# AGENCY# FACILITY iD# #o1 TANKS at SITE <br /> 3 ENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> I ' 'fes PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRAGT�j 8UPERYISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDYES ❑ NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 8 f I BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA{3-2-88} <br /> DATA PROCESSING COPY <br />