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STATE OF CALIFORNIA WATER RESOURCES CONTROL 616ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM l <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMA Y CL D SITE F� <br /> ONE ITEM ❑2 INTERIM PERMIT ID AMENDED PERMIT ❑S TEMPORARY SITE CLOSURE SQ 0000 <br /> I.FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) N <br /> W <br /> FACILITY/SITE NAME c� V) (A)} CARE OF ADDRESS INFORMATION <br /> ADDRESS AG <br /> ^ D ,L NEAREST CROSS STREET ❑ Bmf ❑ PARPMVG ❑ $fATE es � <br /> CITY NAME O{/ �„ STATE ZIP � _ SITE PHONE#,WITH AREA CODE <br /> � <br /> TYPE OF BUSINESS: ❑2 MSMWTOR ❑ 4 ESSOB ✓ .Boz/.V"NDIAN EPA ID # <br /> RESERVATION u ❑ AT TH 8 SITE <br /> ❑ 1 GARSTATION ❑3 FARM OTHEfl TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box to iMicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNT( GENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a STREET ADDRESS ✓Box to indiCate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 11 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: L ❑ II. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3y Elk9l I 1 101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> P <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUNI FILED DATE FILED <br /> rD YES L_INO �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:�� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)0R MORE TANK PERMIT FORM `B' APPUCATI 0 N(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88; <br /> /\� DATA PROCESSING COPY <br />