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i 77 ,'�s•---�-- s <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �5':��-, ' •� <br /> FORM `A': # <br /> UNDERGROUND STORAGE TANK PROGRAM r " <br /> SITE & FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> I COMPLETE THIS FORM FOR EACH FACILITY/SITE `'L,•oRN`' <br /> MARK ONLY F-11 NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> OD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS I NEAREST CROSS STREET :b <br /> nbcEl PARTNE11 STATE-AGENCY <br /> CAROTIO ❑ LOCAL-AGENCY El FEDERAL-AGENCY <br /> Cl INOMDUAL ❑ CGATY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 11,WITH AREA COD <br /> J CA <br /> TYPE O/F�USINESS: F—] 2 DISTRIBUTOR F—]4 PROCESSOR ✓Box if INDIAN EPA IDRESE # <br /> I "AS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTv <br /> vl LANDS ATION or E] N of <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) r PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2091 Z01- 7 2 <br /> NIGHTS: NAME(LAST, <br /> FIRST) PHONE#WITH AREA CODt NIGHTS: NAME(LAST(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME L� CARE OF ADDRESS INFORMATION <br /> MAILING or STIR ADDRESS VINORNICIDUAL <br /> ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Al--A 14- fn( 1 4? <br /> 111. TANK OWNER INFORMATI04 &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF DORESS INO RMATION _ III <br /> MAILING or STREET A KESS '/_ Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> -1 AG yy.���7f 0 Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> "/ / ` •��+ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE <br /> 20 - <br /> gyL <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRE33 SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CQRRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> rPIRMIT <br /> UNTY M JURISDICTION If AGENCY k FACILITY IID} # FoTo-lo <br /> It of TANKS of SITE <br /> ® l V l 4VI �7 k( l <br /> LOCAL AGENCY IFACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> N�R. <br /> UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> N CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> y3 bio YES ❑ NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• <br /> -0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST V-ORMORE TANK PERMIT FORM 'B'APPLICATION(S),UN -SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY ^�^ <br />