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_ ... ..h.snm Z4Nr'K..T,T -R1Tr.T'�., �r{r.n _n4a•x .. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD *''E <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o' o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 P ANENTLY CLOSED SITE I"B' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) J <br /> F`GI^CITY/SITE NAME <br /> Joa N �p �., CARE OF ADDRESS INFORMATION <br /> CLlT76m GFcfr-�& <br /> ADDq1/E$(/$� ,, 1 NEAREST CROSS STREET .✓ roo" ❑ PARTNRENIP Cl STATEA.GEND <br /> I �+�D /XNNG li?m"O Mn(A ❑ LOW AGENCY ❑ FR1fMLAGENLI' I. <br /> CITY NAME El <br /> (_ <br /> � 'j El INDNDUALL O CatiTf AGENCY <br /> �.P <br /> STAT DLJ/ j <br /> STKK CA <br /> l�./ L/� G EaPH�O NE �T2-AREA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR IBox if INDIAN EPA D ## <br /> ❑ 1 GAS STATION ❑3 FARM �5 OTHER RESERVATION or ❑ M of TANK'e <br /> TRUST LANDS L( N AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIR ) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> p'IfriC <br /> i v- v 1 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAM SOVCARE OF ADDRESS INFORMATION <br /> Abo(W <br /> MAILING or STREET ADDRESS ✓Box to md,cate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) I <br /> NAM, Aha CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS U ✓Box io jnajcate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION 8 AGENCY R FACILITY ID k M of TANKS at SITE <br /> 60 20 2 00 0 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> SAti1OO <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CETRASUPERVISOR-DISTRICT P ISTRICT CODE BUSINESS ❑FILED ❑ DATEFI J ED <br /> Z O O YES NO <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE pE 'E1PTV BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONyY^ <br /> FORM A(3-2-88) `� \`C\Jl <br /> �-' DATA PROCESSING COPY <br />