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STATE OF CALIFORNIAV WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Vf4cHANGE OF INFORMATION ❑ 7 PERMANLUILUILWO SITE 1 <br /> ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE NAME n CARE OF ADDRESS INFORMATION W <br /> Al? 09t <br /> ADDRESS L NEARES CROSS STREET ✓alb Mrale ❑ PARINERiHIP ❑ FA7AG30 W� <br /> 3 ��Y D RPoRATHN ❑ LOM MEN(Y ❑ FEDERAL-AGDO <br /> ❑ INDIi ❑ COJWY AGENcr <br /> CITY NAME' ! STATE IP�E� SITE PHON #,WITH AREA CODE <br /> Al V V <br /> TYPE OF USINESS'. ❑ p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # n //J�1 (1 #of TAN <br /> K'# <br /> 7 STATION ❑3 FARM ❑ 5OTHER TRUSTVA'T Ndr ❑ NMI—"'� AT THIS ISITE <br /> CS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME)LAST,FIRST PHONE p WITH AREA CODE DAYS: NAME LAST.FIRST) PHONE p ITH AREA CODE <br /> WILc CdoR � 11- 34roq AI i E P �o `l Y3/-3 / <br /> NIGHTS: NAME(LAST,FIRST) � � PHONE N WITH AREA CODE NIGHTS: NAME(LAS FIRST PHONE#WITH AREA CODE <br /> O 'VYpL�- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE li.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl RPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ IN IDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ If. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ON ODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 9 <br /> a3 , �)� YES NO ❑ -117 <br /> 8 / <br /> CHECK# PERMIT AMOUNT SU AROE AMOUNT FEE CODE RECEIPT If Jay: <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 <br /> WFDBM A(3-2-88) <br /> f)__C) LDATA PRC:ESSING COPY �� <br />