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STATE OF CALIFORNIAw- WATER RESOURCES CONTROb.POARD <br /> f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ILY, NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P LY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (J <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> AQ a) <br /> FACILITY/SITE NAME ?P� CARE OF ADDRESS INFORMATION <br /> 141V�o u.rN u <br /> ADDRESS /! 0 NEAREST CROSS STREET ✓sametiuk NERSHIP ❑ STATE-AGENCY <br /> elCr G 0 00WORATICN LOCk AGENCY 11FEOER4LAGE14M <br /> t <br /> ❑ INONIGUAL MUNtY AGENGf <br /> CITY NAME _ STATE ZI CODE SITE PHONE N,WITH AREA CODE <br /> 7KA// CA ZQ 6 / <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR / ESSOR ✓Box if INDIAN EPA ID a N of TANK'# <br /> RESERVATION or El AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM /5OTHER 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#WITH AREA CODE <br /> i :TAdt 5-77011 JoHifi <br /> NIGHTS'. NAME(LAST.FIRSt) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> N � I <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to indicate TNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION OCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING or STREET ADDRESS `slims_ ✓Box to indicate RTNERSHIP ❑ STATE-AGENCY <br /> 11CORPORATION LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ INDIVIDUAL 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. 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 K AGENCY N FACILITY ID# N o1 TANKS at SITE <br /> 10101 (� I I I 101oo <br /> ff;no <br /> FACILITY IQ / APPROVED BY NAME PHONE N WITH AREA CODE <br /> r/11,M PERMIT APPROVAL DATE - '"� PERMIT E%PIRATION DATE <br /> SUS TRACT N SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED�I " O 'w VESE] NO �MIT 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 /> / FORM A(3-2-SS) <br /> \\�(I/\ `�� DATA PROCESSING COPY AO <br />