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STATE OF CALIFORN6w WATER RESOURCES CONTRbE/BOARD <br /> m <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLLQLQaEU3ITE <br /> ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE ffo3 Y <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) v <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G ulr-- <br /> ADDRESS NEAREST CROSS STREET ✓ 11 ON <br /> ❑ STATE AGSO <br /> 3 . Cu u ❑ nON ❑ LOCA-AGDO 13FE3EW AGENCY <br /> INDMDUa ❑ COUWYAGErvcY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> of ' CA Sod O u4r - <br /> TYPE OF BUSINESS: ❑2 D ,TOR ❑4 PROCESSOR ✓BON ii INDIAN EPA ID N X of TANK's <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GASSTATION FARM ❑5 OTHER TRUST LANDS ❑ <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 /> IS/r! 77 . <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bozla' ❑ PARTNERSHIP 11STATE-AGENCY <br /> ❑ ORATIOaie N 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME dL/l L --,rr CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bort - icele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ 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 BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N Not TANKS BL SITE <br /> 3 ry10I D 1 O 10 1 I <br /> CURRENT OENCY FACfgTY I� APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER rG{'JI VK\ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CfHECK0 <br /> DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 7.3 3aa— res ❑ No ❑PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT• BY: <br /> C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)08 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />