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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM AA <br /> SITE 4ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> i4 <br /> COMPLETE t <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> or <br /> FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT U215'CHANGE OF INFORMATION 7 PERMANENTLY A <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1'f/ <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NA r-PA- C�- S /( 1 CARE OF ADDRESS INFORMATION <br /> Rti lCkA A-K'9 <br /> ADDRESS NEAREST CROSS STREET ✓S,WNeale ❑ PAFTNE1SHP Cl STATE AGFNCI <br /> 11 iNNDQUALI� O C"I RAAGNFCY ❑ FEGEP.ALAGFNLY <br /> CITY NAME STATCA ZIP CODE' e / SITE P 7 <br /> R p,WITH AREA CODE <br /> TYPE OF BUSINESS'. 2 DISTRIBUT 4 Pfl I/R Box it INDIAN EPA ID # (/' S// U{//'L <br /> RESERVATION or of TANK <br /> 1 <br /> I GAS STATION 3 FARM TRER TRUST LANDS1:1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS y NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> (/(NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTTS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME kCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inGlcale ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> S7ibe41i U� �,s2v/ U <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to'.mcale ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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. [:] 11. 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 M JURISDICTION M AGENCY M FACILITY ID M N of TANKS at SITE <br /> � m = = 1 v 2 -7 0 (9 10 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE»WITH AREA CODE <br /> C_EtUiE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS TRACT Y SUPERVISOR-DI RICT CODE BUSINESS PLAN FILED DATE FILED <br /> D 2 �v Z YES NO ❑ Z—� d <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: / <br /> THIS FORM MUST BE ACCOMPANIED BY AT-EAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.,..� <br /> FORM A(3-2-Wo U\ <br /> Ar(` DATA PROCESSING COPY v ) <br /> A V \ <br />