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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> I 1 Vln 1 �n <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT m 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> CfJN <br /> ADDRESS NEAREST CROSS STREET ✓gab Mule 0 PARTNERBIIP 0 STATE A3,M <br /> COWMnON 0 LOCAL-AGM 0 FEDERAL AMID <br /> 5' /xl ❑ IN)MDLK 0 M9 YAGENIX <br /> CITY NAME STATE ZI CODE SITE PHONE If.WITH AREA CODE <br /> S:Ya CA 5,206 <br /> TYPE OF BUSINESS: ❑ 2 DIMIEUTOR ❑1 PROCESSOR ✓Box if INDIAN EPA ID N M 01 TANK s <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ I GAS STATION ❑3 FARM EVOTHEfl TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> Jack-So,U o wa 4 - 7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMy - CARE OF ADDRESS INFORM TION <br /> T- <br /> MAILING or STREET ADDRESS ✓Boz to mrricate ❑ PARTNERSHIP --d STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> y N ).t/ g D INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 57AIC kfa cll� <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF A06RESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa to in0lcate 0 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 N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. Ill.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCYIN FACILITY ID R R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE <br /> N/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT I SUPERVISOR•018MICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3• �S YES NO <br /> CNE K• PERMIT AMOUNT SURCHARGE AMOUNT FEECODE 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 />