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STATE OF CALIFORNiu WATER RESOURCES CONTROL BOARD r��F <br /> EPS T. <br /> W -v <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM 1 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;; <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE �g4iFo R�`P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑L2LMdALjFNTLY CLOSED SITE I �► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C" <br /> Jhb <br /> FACILITY/SITE NAME // CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /'►' v �7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> S7�G �vr� CA 20 <br /> Vl <br /> USINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> S STATION 3 FARM ❑ 5 OTHER TRUST LANDS ATION or ❑ <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /Ie ` ,pie <br /> NIGHTS: NAME(LAAST,T,,FAST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI ) PHONE#WITH AREA CODE <br /> Ste"'/'A""' CJ�L�✓I�.0 l( C I <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSn ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> /► `, p ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (/ (/n/I V��\S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME G/ lP , 21&TATE ZIP COD PHONE#,WITH AREA CODE <br /> ` F -51+ a � D t� _11011� 6:711 <br /> III. TANK OWNER INFORMATION &ADDR SS — (MUST BE COMPLETED) l 505- 240 <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 ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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. k 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 /> v © per <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z-3 o A 0 YES NO //— <br /> CHECK <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT__[FEE CODE RECEIPT# BY: <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 />