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-YR"'PY ..,�.i{ey1�tK�a?_'..gXTTYA"'x�`:x�+'Y/Al; iw.,++f:�f¢��y+.• ,gxr,,Yr ..v.�'.�:, ,..vvlr;.. <br /> STATE OF CALIFORNUIC WATER RESOURCES CONTROL BOARD ' <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT P1 5 CHANGE OF INFORMATION ❑ 7 PERM TLV CLOSED SITE F'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co <br /> C!1 <br /> FACILITY/SITE NAMER�i 5 joj CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET�� NATE AGENi <br /> 0 W=ON O LOCALMENCY ❑ FPARTNERSHIP 0 7EDERi AGENCY <br /> NIVAGEN <br /> CITY NAME � � STATE 'OpZIPCC4 DE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DI UTOR ❑ d PROCESSOR ✓Box if INDIAN EPA IDN J N W TANII Q <br /> 1:11 GASSTATION FARM ❑ 5OTHER TRUSTTVATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: N ST,FIRST) PHONE N WITH AREA CODE DAYSAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -mg&tooti Zob , lic —y6 CCJ <br /> NIGHTS'. NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME j 7 o / CARE OF ADDRESS INFORMATION <br /> MAILING of STREET`/A-DED•/RESS L•,r/'-/ ^^ � ✓Box to intlicaie C3 PARTNERSHIP 13STATE-AGENCY <br /> — ` ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> STI, ✓ 9 Su <br /> Ill. <br /> � 6 - <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Box Io indict 11 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ElCOUNTY-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. ❑ 11. ❑ If.❑ <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 FAC N of TANKS N SITE <br /> D <br /> CURB E OCAL AGENCY FACILITY ID N APPROVED BY NAM PHONE N WITH AREA CODE <br /> PERMIT NUMBER ATE PERMIT EXPIRATION DATE <br /> cl <br /> LOCATIOJ/CODE CENSUS TRACT N� SUPERVISOR-DISTRI T CODE BUSINESS S N❑FILED NO ❑ DATE FILED `— If 41 <br /> CHECK* ql PERMIT AMOUNT SURCHARGE AAMMO NT FEE CODE RECEIPT* BY: <br /> w2f <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 /> FORM A(3-2-SB) <br /> DATA PROCESSING COPY <br />