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bE'iu�eRn..Nf <br /> STATE OF CALIFORRO WATER RESOURCES CONTR�Ci BOARD p <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' � Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONto <br /> 09lIFORNIP <br /> /� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> l� 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 140 <br /> � <br /> MARK ONLY ❑ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACI SITE NAME 1311 S <br /> NEAREST CROSS STREET ✓Box I61&nb PAAMEASHIP 0 S1AIEAGDMO <br /> ADD SS / (Z / ❑ COAPGHAiION ❑ LIX'AL-AGFNLY ❑ FEGEPAI.ASENCI' <br /> J 7^ I ❑ INDIVIDUAL ❑ COUNIYAGO C/ <br /> STATE Z CODE SITE PHONE p.WITH AREA CODE <br /> CITY NAME 11 D CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR -/Box if INDIAN EPA ID X p of TANKS ' <br /> RESERVATION or ❑ AT THIS SITE <br /> F-1FJd' <br /> 1 GAS STATION ❑ 3 FARM n 10THER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY ' NAME(LAST.FIRST) <br /> PHONENWITH AREACODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> Q PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME( /.�FIRSST)� <br /> SW/ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> /3 oe K6 rv tjQ P1 <br /> MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP 0 STATE-AGENCY <br /> 3 D CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> STAT11 INDIVIDUAL O COUNTY-AGENCY <br /> S /I ZIP CODE PHONE p.WITH AREA CODE <br /> CITY NSAMEICO C �"—/F cI rl `� <br /> C, JC ! J <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> 2� w e <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE a.WITH AREA CODE <br /> CITY NAME <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 /> 0 1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION p AGENCY p FACILITY ID# #of TANKS at SITE <br /> 07E= oar <br /> CURRENT CAL AGENCY FACILITY ID X <br /> APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT N MBER 5 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS ACT M SUPERVISOR-DISTRICT CODE BUSINESS <br /> SPLANFILED NO ❑ D�E FILE or <br /> yk- <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT If Stir: <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />