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STATE OF CALIFORNN WATER RESOURCES CONTROBOARD <br /> FORM 'A': <br /> SIT UNDERGROUND STORAGE TANK PROGRAM <br /> FA ITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> :c <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PE TLy CLOSED SITE F—a <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE i'S I -I <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) (/ Ln <br /> FACT BITE NAM CARE OF ADDRESS INFORMATION IV <br /> ADDRESS <br /> SO NEAREST CROSS STREET ✓Bo ygiate 0 PARTNERSHIP ❑ STATE AGENCY <br /> /w� (�" / LSVGOAPOR Moll ❑ LIKAL.AGENCY 0 FEGEAALAGENCY <br /> 0 INDIVIDUAL Cl COUNTY AGENCY <br /> CITY NAME t'-' j STATE ZIP DE <br /> J�If.C.�JN SITE PHONE WITH AREA CODE <br /> TYPE OF BUSINESS: 0 p DISTRIBUTOR 0 4 PRO SSOR '/Box if INDIAN EPA D 4A ��, ^ D 1 GASSTATION E] 3 FARM OTHER RESERVATION or N of TANK's <br /> 1:1 /wml TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> Pr to e ; Cao <br /> NIGHTS: NAME ST,FIRST) 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> Sum.-�-e,. <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILIN"G�,�or STREET ADDRESS BO intlicale ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 1 Alf— <br /> RPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> d� ❑ INDIVIDUAL 0 COUNTYAGENCYCITY�[y4h]E G / 9T ZIP C17t�5 PHONE 4,WITH AREA CODE <br /> q. <br /> 111. TANK OWNE INFORMATION & ADDRESS— (MUST BE COMPLETE(DD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lO indicate 0 PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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: 1. Il. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY N FACILITY ID k a of TANKS at SITE <br /> Qa % 1 -71 (3-171 00 � <br /> CURRENT LOCAL Azio <br /> APPROVED BY NAME PHONE#WITH AREA CODE�PERMIT NUMBERAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODESUPERVISORIDISTRI T CODE BUSINESS PLAN FILED OAT FILEDl YES ❑ NO ❑CHECK SURCHARGE AMOUNT FEE CODE RECEIPT# BY; V <br /> ass aaaaaaaa <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 , <br />