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STATE OF CALIFOI'[IIYIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': t o <br /> UNDERGROUND STORAGE TANK PROGRAM _ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m �; <br /> (� COMPLETE THIS FORM FOR EACH FACILITY/SITE I-�� <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 NT CHANGE OF INFORMATION ❑ 7 PERMANEED SITE z <br /> ONE ITEM ❑2 INTERIM PERMR ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> Cry1�� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> wo/ /c <br /> ADDRESS °° � NEAREST CROSS STREET IV/ IN ❑ PARTNERSHIP ❑ STATE AGEND <br /> �� S /v- Gt//9/rJi'Y <br /> CORPORATION ❑ LOCAL AGENCY ❑ FMM AGENCY <br /> �/'P/A'I O/�f ❑ NGNOA ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A,WITH AREA CODE <br /> CA � <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR -/Box it INDIAN EPA ID x <br /> RESERVATION or F of TANK'F <br /> ❑ I GASSTATKIN ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ c F9C coo /S,3l q 7 AT THIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE V WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> -v -1d 3/ f , <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA ODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA ODE <br /> ✓Gtctei r2-2 15- 7,)-(o�a7 1 , . , <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ice Com <br /> MAILING or STREET ADDRESS //-- ✓ oinaiCale El PARTNERSHIP ❑ STATE-AGENCY <br /> ErCORPOIRAT_57-5 C' //1 L f[J/9 Cl NDIIVIDUALION COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA ODE <br /> A ins c� 900ye a/3 - �� v- 9sso <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Same as a6'ov� <br /> MAILING or STREET ADDRESS ✓Box to inCicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ R. 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 /> COUNTY11 JURISDICTION F AGENCY k FACILITY ID A F of TANKS at SITE <br /> 3 y 3 1 a 10 1 o 1 a I y / `/ D 1 U I D <br /> CURRENT LOCAL AGENCY FACILITY ID P APPROVED BY NAME PHONE F WITH AREA CODE <br /> GlN/D/U � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTF SU PERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED/ <br /> 3 c�-O 3 a3 YES NO <br /> CHECKF PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: n'2 <br /> 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FO RM 'B'APPLICATION(S), UN#HIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(32BB) _ <br /> DATA PROCESSING COPY <br />