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STATE OF CALIFORM'A WATER RESOURCES CONTRZi BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° : ; 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Q�AEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMA LY CLOSED SITE F'a <br /> ONE ITEM I1B 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> �.I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS41 C- x./ NEARE 7`NCRQSSSTREET PMpb ❑ PURNEABNP ❑ Si4TE-,I/i kV <br /> COflPoR4iKKV ElIOGlAGENf.Y ❑ ROEIULM-RGENLY <br /> INBMDW ❑ COUWYAcEKCY <br /> Cltt NAME STATE ZIP CODESITE PHONE N WITH AREA CODE <br /> Phi✓ <br /> s cA SZo 6 20zP <br /> TYPE BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boa it INDIAN EPA ID N <br /> RESERVATION or Not TANMa / L <br /> 1 GAS STATION 3 FARM ❑ 50THER TRUST LAND$ ❑ AT THIS SITE 7 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> VA <br /> AnM/&e ,toy- 5?40 2? J'A_V� , <br /> NIGHTS: NAME(LA / PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 6,4WAI d CSG DGve41 ,�/ ,e�i7 �3*A/Tv wos/ <br /> MAILING or STREET / R�S ^,1 910 ��� to indicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> V CORPORATION 0 LOCAL-AGENCY 13FEDERAL-AGENCY <br /> //( <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> LW 0T F/ Wr-537-1019 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) A!FX <br /> NAME A ^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSx to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS N SITE <br /> = = F 6_ ado <br /> CURRENT LOCAL AGENCY FACITY ID L�05 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER /) PEflMI//PPROYAL DA Ji WKnfPPEERMIT EXPIRATION DATE <br /> L^PEE <br /> LOCATI/O�N CODE CENSUS TRACT MSUPERVISOR-DISTRICT CODE BUSINESS PLAN NO N FILED DATE FILED <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> 1i' DATA PROCESSING COPY �"'� <br />