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STATE OF CALIFORNIA WATER RESOURCES CONTROL BO•D '`^' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITEACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONL ❑ I NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ffr-7 PERMANE 0 SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CRO SSTREET ✓BoxbiMule 0 PANTH Nip 0 STATE AGENCY <br /> 0 CpPCIUNON 0 LOCAL AGENCY 0 FEDERALAGENCY <br /> 7 47Wilalte , 0 INDIVIDUAL 0 MINT#GENCY <br /> CITY NAME LA r \ /1 <br /> STATE ZIP CODE $I1E P'7 N 2 7-REA C D <br /> TYPE OF BUSINESS: ❑ 2 DIST UiOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N /W-,O_ N of TTANNK's <br /> ❑ I GAS STATION 3FARM ❑ 5OTHER TRUSRESETVATION LANDS or ❑ AT 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 WITH AREA CODE <br /> •109 �g7-.3� <br /> NIGHTS: NAME( .FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME L CARE OF ADDRESS INFORMATION <br /> A <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> n ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERA GENCY <br /> 1 yuV 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,W THA OE <br /> IL�:1�1o2e� Cl/F Sa3ly ao9 �� -36y <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s � <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ it. ❑ 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 /> COUNTYIN JURISDICTION R AGENCY k FACILITY ID N R of TANKS at SITE <br /> [3M = = 10101Y / I ell aoo <br /> CURRENT LOCAL AOENC FA ILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER 0 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED TE FILED Q V-1S <br /> YES [:] NO 0 Yip, <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($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> DORM A(lry3y-92�-SB) j <br />