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STATE OF CALIFORNIAWATER RESOURCES CONTReBOARD F <br /> W. <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> F <br /> ARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 CLOSEO SITE 1%0 <br /> NE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Ln <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W 1 <br /> FACILITY/71'E"NAME <br /> n^' '^ CARE OF AD ESS INFORMATION <br /> w/rwr <br /> ADDRE l ^e ,x - N EST ROS$.ETREFJ ✓Bo. iVe ❑ PAWNERSHIP ❑ STATE AGENCY <br /> (//(� \Y•,l[ N ❑ PORATION ❑ LOCAL ❑ FEDEML AGENCY <br /> INDNIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATEZ .SITE PHON WITH AREA CODE <br /> a CAZ° 333 Zo3o <br /> TYPE OF BUSINESS ❑ Z 7 UTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 7 GAS STATION 3 FARM 5 OTHER RESERVATION or �] AT THIS SITE D <br /> ❑ TRUST LANDS ❑ /'p / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAN NAME(LAST,FIRST PHONE A WITH AREA CODE DAYS: NA (LAST,FIRST) PHONE1ITH AREA CODE <br /> X33 ZoO S A ,Q <br /> NIGHTS. NAM (IA F ST) PHONE#WITH AREA CODE NIGHTS'. N E(LAST,FIRST) PHONE# ITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME/- " CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ) <br /> Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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 or STREET ADDRESS ✓Box to wdicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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: I. z it. ❑ 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 /> 06 1 7- 3 Cab 10 11 <br /> CUNBEX OC_AL AGENCY FACILITY IO# APPROVERNAM ��� PHONE#WITH AREA CODE <br /> PERMIT NUMBER 2 PERMIT APPROVAL DATE ,//f[//`PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR. DISTRICT CODE BUSINESS PLAN FILED DATFIILLEED� <br /> (-(f 2' TZ-0 YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 /> �DRM A(3-2-88) J <br /> DATA PROCESSING COPY .,� <br />