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STATE OF CALIFORNIA WATER RESOURCES CONTR•BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> 110 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Iz <br /> 10 <br /> - COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 w <br /> w <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Q <br /> FACILITY/SRENAME CARE OF ADD SIN O MATT ��VV <br /> e� he Cir m ITS 04 Sf kr1 I P ❑ <br /> ADDRESS NErST CROSS STREET <br /> ROOSSSSTREEETT ✓ 0100NCl PARTNERSHIP ❑ STATE AGENCY <br /> LII �50 S h HFEDERALAGENC <br /> f <br /> `.0 �-/ 13IOryDDADCONY AGENCY <br /> CITY NAME /1 fo c �n <br /> �`J� If/` STATE ZIP ODE SITE PHnONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID aA �� O-I �LI �` <br /> ❑ 1 GAS STATION ❑ 3 FARM -&-OTHER TRUSTREVLAND5 or <br /> ❑ AT THIS SI <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA ( $T,FIRST) PHONE#WITH AR ASTFI <br /> A CODE DAYS NAME(L , RST) PHONE N WITH AREA CODE <br /> PJi I 1 a�, i � <br /> NIGHTS: NAME(LAST,FIR$ PHONE# �llJT_ C? � ct <br /> WITH AREA CODE NIGHTS. NAME(LAST FIRST) PHONE H WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF�aRESS INFORMATI <br /> l�� OF n �r l c _A T SA7n.L to h I a (s r C�flo <br /> MAILING or TREET ADDRESS 1 ✓q ^ ^dicate ❑ PARTNERSHIP 1-1STATE-AGENCYCORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ClCOUNTY-AGENCY <br /> CITU NAME 1 iL STATE ZIP QODE� ` PH 4 WITH AREA CODE <br /> (`(S 3� q� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> �' n CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS l.X B.t.,mcate Cl PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCALAGENCYEl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.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. ❑ if. [?I-- 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 If AGENCY# FACILITY ID If #of TANKS at SITE <br /> m = 101ol l --*, q DouU <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> EPERMIT NUMBER UU PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> TI DE CENSUS T C # SUPERVISOR ISTRIC CODE BUSINESS PIAN FILED D E FILE I � I I j <br /> VES NO <br /> 0 0 r(7A <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 1 / THIS FORM MUST BE ACCOMPANIED BY AT LEASIPR 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 />