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y'/•'•fu XO[K�••T�F <br /> STATE OF CALIFORNO WATER RESOURCES CONTRO BOARD e s <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C4�IFORN P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE P� <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE el � <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) aQ <br /> FACT /SITE NAME CARE OF 4DDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET �✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> // CJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ®( yhwlk� /�►.�G / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 4 SITE PHNE It,WITH AREA CODE <br /> L,llQi CA 4?_C2�-r-10 I <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # If of TAINK's <br /> �1 GAS STATION ❑ TRUST LANDS ElO`y 3 FARM ❑ 5 OTHER RESERVATION or /� AT THIS SITE 0 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: N ME(LAST,FIRST) PHONY# ISI AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: WAME(LAST,FIRST) PHONE#WIJH AREA CODE <br /> 010 YZ-d`z`!b1 S LA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> Nq CARE OF AD IRESS INFORMATION <br /> ka&Z6 <br /> MAIL jt or STREET ADDRESS ✓qox to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> S CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY ME • STATE ZIP CODE LPHONE#,VVITH AREA CODE <br /> C .?0 lS d 6rf Zw zeal <br /> III. TANK OiR 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 ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. 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 /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ffa] I I I j E[ Da l kia <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Cb U 161-2.4 ' <br /> PERMIT , VAL A E PERMIT EXPIR TION DATE <br /> CENSUS TRACT# SUPE ISOR-DISTRICT CODE BUSINESS PLAN FILED D/AAT,E/FFIILED <br /> 4U YES NO r�D l�" 0 2 <br /> 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 /> FORMA(3-2-88) 0 <br /> DATA PROCESSING COPY 0 <br /> S <br />