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STATE OF, CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': - • . �, <br /> UNDERGROUND STORAGE TANK PROGRAM ��` � fto <br /> C SiT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -„m,, o <br /> 1 G, COMPLETE THIS FORM FOR EACH FACILITY/SITE C�I,FOP�' <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> i <br /> N <br /> .1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME A CARE OF ADDRESS INFORMATION <br /> d'd Ile qe vi /` I” <br /> ADDRESS NEAREST CROSS STREET ✓Box b indicate ❑ PARTNBiSHIP ❑ STATE-AGDICY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 ' M S a+ ❑ WDMIX1Al ❑ COUNTY-AGENCY <br /> i CITY NAME STATE Z CODE SITE PHONE N,WITH AREA CODE <br /> SAO C_ 4-0ve- CA 1 5 AL o5 <br /> i TYPE OF USINESS: EPA ID N <br /> I 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN <br />[ ❑ ❑' TRUSTYLANDS ATION or ❑ 0 of TANK <br /> GAS STATION 3 FARM OTHER AT THIS SITE <br /> i <br /> EMERGENCY CONTACT PERSONI(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C .201 6-732 <br /> NIGHTS: 4MIE(LAST,FIRS ) 0 VPHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I tI le — P3 71, <br /> i <br /> I II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> I <br /> I NAME i CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS v -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAV f STATE ZIP CODE PHONE It,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. ❑ if. ❑ 111.❑ <br /> E <br /> i 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION 0 AGENCY 0 FACILITY ID 0 0 of TANKS at SITE <br /> o � I 'A � Fo�o a 1,-4 <br /> CURRENT LO AL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE S WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT tt SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> j ! a YES NO 12 l3 0 <br /> CHECK If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N SY: <br /> i <br /> a <br /> THIS FORA 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) ^-t <br /> {r DATA PROCESSING COPY ' <br />