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OF- <br /> STATE OF CALIFORIO WATER RESOURCES CONTRO BOARD <br /> 4 iEn <br /> v. <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE/, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> y COMPLETE THIS FORM FOR EACH FACILITY/SITE =" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED�SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 V O <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 00 <br /> 4 <br /> FACILITY/SITE NAME •e/1' Lai /1 CARE OF ADDRESSI FORMATION LACI <br /> ADDRESS IU' n 1 `�JIL. NEAREST CROSS STREET ✓1Ip«1014M ❑ PARTNERSHIP D STATE AGENIX <br /> 1 ( �'^ I ❑SOPogNATION D LOCAL AGM D FEDERALAGDO <br /> ` <br /> 1 .S�NDNIWAL D COUNTY AGENCY <br /> CITY NAME IS�,. L STATE ZIP CODE SITE PHONE IT WITH AREA CODE <br /> 1 l� 4z i") CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or / N of TANK <br /> 's <br /> 1 GAS STATION ❑ 3FARM ❑ 5OTHER TRUST LANDS ❑ ✓ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) N PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> tA \� <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME1 % I CARE OF ADDRESSINFORMATION <br /> MAILING or STREET ADDRESS ✓Box toindicate Cl PARTNERSHIP D STATE-AGENCY <br /> + (� ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ✓T <br /> �( , `Cot V'1 Vj <br /> e D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L e-i I C c_(a c v- <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATE-AGENCY <br /> C^ 1 D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> q U (1 � i \1 Ov D INDIVIDUAL D COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> A (21:219 i yam -) 9 <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. ❑ If. <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 R JURISDICTION R AGENCYIN FACILITY ID M k of TANKS at SITE <br /> = = I A K= I ploG , <br /> CURRENT LOQ/1L�GEf/¢�CILITY <br /> �( ID Nq APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER YY �� PERMIT APPROVAL DATE PERM IT EXPIRATION DATE <br /> DE CENSUS"ACTIN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE/FILE <br /> C.I YES ❑ NO ❑ C,Lu <br /> [C=HECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 ONLY. <br /> FORMA(3-2-88) <br /> 0 DATA PROCESSING COPY 0 <br />