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STATE OF CALIFORN� WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE U CD <br /> 00 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> SI1 rX <br /> ADDRESS NEAREST CROSS STREET ✓ft to alail¢ PARTNERSHIP ❑ STATE AGENCY <br /> Ar <br /> LID <br /> �\^ p ❑ CORPORATION 11LEGALAGENCY D FEDERAL <br /> ' <br /> I I 0 S • Lo A�ar% ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP COpp�� SITE PHONE M,WITH AREA CODE <br /> R On , Ccs CA `15310(0 020` (oT2220 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID pESE <br /> p of TANK'e <br /> ❑ 1 GAS STATION [:] 3 FARM L3'0THER TRUSTYATION LANDS o ❑ AT THIS SITE b <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS' NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> X09 as v <br /> NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE <br /> I1 0 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rYLA CX O <br /> MAILING a,STREET ADDRESS ✓Box to in7icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 0.rv,_ <br /> MAILING a,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE K,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. 11. ❑ 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 /> COUNTYII JURISDICTION N AGENCY M FACILITY ID a IF of TANKS at SITE <br /> 3q I1 do I olI <br /> CURRENT LOCAL AGENCYFAC ITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> O SI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE <br /> /FILED <br /> �l L I'a_ t YES NO ❑ `-l.Lit- ( I <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM BUST BE ACCOMPANIED BY AT LEAST(1)OR 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 "L <br />