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STATE OF CALIFOR& WATER RESOURCES CONTROL BOARD ze`.""^ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION10 <br /> , <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> FMARK ONLY f NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE IT <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> co <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BMW idiaile ❑ PAAINBWP 0 STATEAGDV <br /> D WIPGRA70N D LOCAL-AGENCY D FEDERNAGDO <br /> /77Gf/'A OSCt El wcm m 0 ODUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> ti CA °/Sdo,S 50f,4 9'Ale-4"s' <br /> 1YPE OF USINESS: 2 DISTRIBUTOR 4 PROCESSOR -/Box if INDIAN EPA ID a <br /> RESERVATION Or '' //// #of TANK'# <br /> TYPE <br /> GAS STATION ❑ 3 FARM ❑ S OTHER TRUSTLANDS ❑ Wlc_ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) N:WITH AREA CODE <br /> ¢Z G v arru <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> // it le <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING arREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> $Q 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> s n. C'!9 I 915a0s <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> - <br /> MAILINGorSTREETADDRESS ✓Bax to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYA, JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> 39' Oo 1 / & I 7i I 10 1 a� & 1 5- <br /> CURRENT LOCAL AGENCY FACILITY ID# 1 Ly Z- APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION ATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a YES ❑ NO ❑ 8 d L/-e? <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 4 <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) 10 <br /> DATA PROCESSING COPY • <br />