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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> S7 —.7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7�{iMARf4iT Y C11111:11$ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -r 1 0 <br /> FACILITY/SITE NAME CARE OF KESS INFORMATION <br /> / <br /> ftw� <br /> PWNE <br /> NEARETC ✓ 1AHP 130 CMDUTIIOX ❑3 LOCA.-AENGY ❑ SfA7EJGENLY <br /> NQ0❑ Rumm 13 CIDIMAGBIC/ <br /> (p <br /> CITY STATE ZIP CODE SITE PHONE M,WITH AREA CODE W <br /> CA <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑d PROCESSOR I ✓Box if INDIAN EPA ID 4 <br /> RESERVATION o, N of TANKS <br /> I GAS STATION 3 FARM ❑5 OTHER TRUST LANDS ElAT THIS SITE <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 /> NIGHTS'. NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTSNAME ILAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓Box to ilMicete D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE I,W ITH AREA CODE <br /> III. TANK OWNER INFORMATION 8t ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box m V of . D PARTNERSMP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,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. ❑ 11. ❑ 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 /> COrnNTY K JURISDICTION M AGENCY M FACILITY ID K B of TANKS at SITE <br /> 4 G D 3 L D D 1El J <br /> CURRENT LOCAL AGENCY FACILITY IDI APPROVED BY NAME PHONE I WITH AREA CODE <br /> '4/?--s 00 Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DA RLE <br /> YES NO 9 / <br /> \ CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE IKT(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br />