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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> r����ppyy <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM Z <br /> S�T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH;f ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> c es <br /> ADDREr NEAREST CROSS STREET ✓ iMole 0 PA ESHIP 0 STATE-AGENA <br /> X' 0RATON 0 LOMAGEAD 0 FEDERALADM <br /> { ('(� IWMDt AL 0 DJUNN AGENU <br /> CITY NAME v V T V STATE ZIP OCE SITE PHONE k,WITH AREA CODE <br /> CA d <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR d PROCESSOR -/Box if INDIAN EPA ID X %of TANKs / <br /> F—] I GAS STATION F__] 3 FARM [{ '40THER TRUSTT LANDS ESERVATION or ❑ N(J /"`0— AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> GHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING r STREET ADDRESS ✓ to ir,tlieate Cl PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAM STATF ZI CODE PHONE X,WITH AREA CCOE <br /> ]60 <br /> C'K <br /> Ill. TANK OWNER INFORMA ON & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE�tST OF MY KNOWLEDGE,IS TRUE AND CORRECT, <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY N FACILITY ID N If of TANKS at SITE <br /> I I I a13 1 lnb la 1 ik <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBERRMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PE <br /> LOCATION CODE CENSU A T SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1'1 YES E] NO /R/070 f:l <br /> CHECK# PERmrr AMOUNT SURCHARGE AMOUNFEE CODE RECEIPT# BY: <br /> / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM {B1 APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / FORM A(3-2-88) <br /> Y tii DATA PROCESSING COPY <br />