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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM4P A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> T <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A)*�, e . Ino <br /> ADDRESS! NEAREST ROSS STREET ✓EwbFAUK 0 PARTNERSHIP ❑ STATEAFiENLY <br /> J, S�` Comm /<-'e- 0 I li O tMA GOBI ❑ PEGEwL-AC#NL1' <br /> CITY NAME STATE ZIP CODE SITE PHONE A,WITH AREA CODE <br /> S4aC.'kDN CA - <br /> TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INOIAN EPA ID N <br /> RESERVATION a N of TANK'S <br /> ❑ t GPS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST IRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> y66- y <br /> NIGHTS'. NAME(LAST,FIRST) PNE N WITH AREA CODE N�GP NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> L i 6 727 t <br /> — <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G QS Zr <br /> MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 6 ' CARE OF ADDRESS INFORMATION <br /> 6S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ 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: 1/0If. ❑ 111. ❑ <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• JURISDICTION B AGENCY M FACILITY ID R R of TANKS at SITE <br /> ffm © 0 o 'd 6 Fal D 10 10 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE <br /> Cgur ?i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOIACODE C7;TMCT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILED <br /> I Eby YES NO �S <br /> CHECK A PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 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 ONI�Y.', <br /> / FORM A(3-2-88) % <br />