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ANATE OF CALIFOR WATER RESOURCES CONTRII BOARD <br /> -FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Pct <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Cr <br /> il Z <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS J r NEAREST CROSS STREET indicate ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> � ❑ NmIDUALION 13 COUNTY AGENCY 11 LCII ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODESSE PHONE#,WITH AREA CODE IV <br /> 1 �{ CA ' <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box 4 INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑3 FARM �fER TRUST LANI DS or ❑ /(-(Nf c..122� AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Roil,? <br /> r, w iI LA&6- tM+ieti f�(o5`laS3 <br /> NIGHTS. NAME(LAST,FIRST) P NE#WITH AREA CODE NIGHTS: NAME(LAtT,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 9� y CARE OF ADDRESS INFORMATION <br /> AW, <br /> MAILING or STREET ADDRESS ,_� o indicate El PARTNERSHIP © STATE-AGENCY <br /> 0KORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C/ _. / E3 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,.WITH AREA CODE <br /> ���Sr a ib5 3 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ IN_DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. 0 if. III. [:]771 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICAN'T'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS et SITE <br /> © / 1071:01:� <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> /3 - 4e <br /> LPERM'TNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCENSUS TRACT* SUPERVI R-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> 23•Q6 YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 6Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) 41 <br /> DATA PROCESSING COPY 7�' <br />