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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ,a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO <br /> v COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> _ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM TLY Cl SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT ❑ E TEMPORARY SITE CLOSURE / L <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) En <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 05 1Li.tnlDrS yr/li <br /> ADDRESSr� -/ NEAREST CROSS STREET ✓Bmombcsa 0 PAMN W 0 STATE AGENLY <br /> KNA <br /> I "1 -7DO I� GDAiIDN ❑ LOCAL LT ❑ <br /> AGENEEOERLL NCI <br /> AGE <br /> ❑ INDYIW TI ❑ OCAL -AC{Nf.Y <br /> CITY NAMESTATE ZIP CODE/ SITE PHONE A.WITH AREA CODE <br /> CA 1 <br /> TYPE OF BUSINESS: EPA ID x <br /> 2 DISTRIBUTOR 1 PNOCESSOq ✓Bawd INDIA <br /> RESERVATION a Fol TANSY <br /> ❑ 1 GAS STATION ❑ 7 FAIN/ ❑ S OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS- ME(LAST.FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE x WITH AREA CODE <br /> w � , b u - g2. <br /> NIGHT NAME(LAST.FI T) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE F WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.STREET ADDRESS ✓Box Io indica,. 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL.AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a STREET ADDRESS ✓Boa to indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x,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: I. ❑ II. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> L LOCAL AGENCY USE ONLY <br /> COUNTY Y JURISDICTION a AGENCY X FACILITY ID a M of TANKS at SITE <br /> ?-T E= = a Fe) <br /> LCURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHO a-VIR AREA CODE <br /> LPERMIT NUMBER PERMIT A PROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES ❑ NO 11 66 <br /> CHECKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT) BY: <br /> 3 i 9d <br /> L THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION(SI. IINLESS THIS IS A CHANGE OF SITE INFORMATION\Ia <br /> FORM A(3-2-881)v \ <br /> ,r" DATA PROCESSING COPY �� <br />