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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': W•' <br /> ate = 1 <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> l� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ 7PERMANENTLY-CLOSED SITE N <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE y' <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) / <br /> FACILDWSITE NAME p 4b <br /> CARE OF ADDRESS INFORMATION <br /> Scr��r rs h'1 Gn <br /> O- <br /> ADDRESS , <br /> NEAREST CROSS STREET ✓A oindra@ ❑ PARTNERSHIP 0 STATE AGENCY <br /> S, c C An lC GRPORATION 11 LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> CITY NAME INDIVIDUAL ElCOUNTYAGENCY <br /> STATE ZIP CODE SITE PHONE 4,WITH AREA CCODE CA 9s' p <br /> TYPE OF BUSINESS 2DISTRIBUTOR 4PROCESSOR ✓ <br /> ❑ Bull INDIAN EPA ID p <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY NTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME( FIRST) <br /> PHONE 4 WITH AREA CODE <br /> - <br /> NIGHTS NAME(LAST,FIR ) PHONE N WITH AREA CODE NIGHTS: ME(LAST,FIRST) <br /> PHONE kWITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUS E COMPLETED) <br /> NAME / C E OF ADDRESS INFORMATION <br /> le <br /> MAILING or STREET ADDRESS ✓(fox to in0icate ❑ PARTNERSHIP(,r C�� ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> CITU NAME ❑ INDIVIDUAL 11 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> Ju�EsJ�r C,4 1 9151111.1 <br /> III. TANK OWNER INFORMATION & ADDRESS — UST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> .�- <br /> MAILING or STREET ADDRESS ✓Uox to"o'cate ❑ PARTNERSHIP <br /> ❑ CORPORATION ElLOCAL-AGENCY0 STATEAGENCY <br /> ❑ INDIVIDUAL 01 COUNTY- FEDERAL-AGENCY <br /> CITU NAME AGENCY <br /> STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING DORESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADD SS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ff If. ❑ <br /> THIS FORM HAS BEEN COMPLETED UND PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNAT D DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION#/ AGENCY# FACILITY ID# <br /> #of TANKS at SITE <br /> 3q O o0 <br /> CURB NT OCAL AGENCY FACILITY ID p / APPROVED BY NAME <br /> \ y � PHONE WITH AREA CODE <br /> PERMIT NUMBER 1 PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DGG <br /> O � / _ � Z YES NOATE FILED O�Zb <br /> EmI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX <br /> BY: <br /> THIS FOfl1A MUST BE ACCOMPANIED BY AT LE <br /> FORMA(3-2-88) Iff)OR MORE TANK PERMIT FORM 'B'APPLICATAPPLICATION(S)WSW• IS A CHANGE OF SI FORMATION ONLY. Cj <br /> 10—1I?l 10 0 DATA PROCESSING COPY O <br />