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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> SFMARK <br /> UNDERGROUND STORAGE TANK PROGRAM ... <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ir1 <br /> �roaH'n <br /> ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT TEM 5 CHANGE OF INFORMATION �O7RMANENT CL SED SITE '2y' <br /> 2 INTERIM PERMIT 3 AMENDED PERMIT <br /> 6 TEMPORARY SITE CLOSURE •Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME W <br /> n;/N/[Llk r,Awi CARE OF ADDRESS INFORMATION <br /> W( ,per` W <br /> ADDRESS <br /> /�.I.e/I K..� N <br /> E ESTEGODE <br /> ✓eftw sK ❑ PARMBOfIP ❑ FATE AGENCY <br /> ❑ UN ❑ LVCIL AGENCY ❑ fEOFRgL AGENLI' <br /> CITY NAME qUi ❑ 000NTY AGENCY <br /> SITE PHONE N.WITH AREA CODE <br /> Cao 3& - <br /> TYPE OF BUSINESS: ❑ 2 0 RIBUTOR 4 PgOCES50R ✓Box if INDIAN EPA ID a <br /> � 1GA5 STATION 3FARM � SOTHER TRUSTLANDS VATION or ❑ /1 /�, „ fAT <br /> OII ' D <br /> V V ��� THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE If WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> R. 1 ah Caoq -30- 9 <br /> NIGHTS: NAME(LAST.FIRST)) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C a4-v� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or EET ADDRESS ✓Box to lnalcate ARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (DUAL ElCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREACODE <br /> ko X19 9 Sa`f0 ao 3 - q <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or ST EET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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. 0 11. 10 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 B JURISDICTION R AGENCY N FACILITY ID N of TANKS BI SITE <br /> `t I 3JA D D O <br /> CURRENJCL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> CA 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> LOC7N DE CEN TRAC � SUPERVISOR-DIS ICT CODE BUSINESS YES#❑FILED NG ❑ ATE//F ^ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: /L, <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 /> ORM A(3-2-88) <br /> � DATA PROCESSING COPY � <br />