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STATE OF CALIFORNI WATER RESOURCES CONTROBOARD "" <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" 'a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �/ PERMANENTLY ITE <br /> � <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CX7 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) t>T <br /> FAOI ITV/SITEN ME CARE OF ADDRESS INFORMATION <br /> ADDRESS N REST CROSS STREET ✓Bos t,,Pr.S 0 PARTNERSHIP 0 STATEAGENCY <br /> SfA 4,/ 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL <br /> &INDIVIDUAL 0 --AGENCY <br /> STATE ZIP CODE SITE PHONE k.WITH AREA CODE <br /> CITY NAME hoc CA �� .17 p —Nd <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 PROCESSOR -/Box it INDIAN EPA ID # #of TANK's <br /> ❑ ❑ RESERVATION D ❑ AT THIS S1TE <br /> F-11 GAS STATION Rr3 FARM ❑ 5 OTHER TRUSTANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> P r ' p - -S,6'9 <br /> NIGHTS'. NAME(LAT FI S ) /F PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> i <br /> MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP E3 STATE AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> S 5`e Al roziX 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rorp <br /> MALINGorS EET DDR SS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY <br /> DIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIPCODE PHONE k.WITH AREA CODE <br /> Loc _o ad c , I 9lr­ 3 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS ry <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. LI II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE DATE <br /> ru N <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# —� #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY I _ APPROVEP B "ME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXP RATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> YES NOCKJ/. <br /> CHECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <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 0 Y. <br /> FORMA(3-2-68) <br /> ��1111VVVIIII�����v/// DATA PROCESSING COPY <br />