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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V <br /> =mom Ado <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -0 : o <br /> G COMPLETE THIS FORM FOR EACH F ILITY/SITE �"'�o"='" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ILK CHANGE OF INFORMATION ❑ 7 PERMANENTLY ED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Fay=jjJw 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Ca <br /> Ja <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS SIRE ✓8orq nEiule ❑ P IP ❑ STATE AGENLT <br /> .), 005- O 00FP0RhTTGN ITIM ❑940 Ownw� 0 FRIEWAGEND <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> szfoG CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ^❑ 4/PROCESSOR ✓Box if INDIAN EPA 10 p <br /> ❑ ❑ tl RESERVATION o ❑ M of TANSY <br /> 1 GAS STATION 3FARM OTHEfl AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS' NAME LLAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATI N &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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 ✓Bax to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNW-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR kTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION M AGENCY# FACILITY IDB M of TANKS at SITE <br /> Eu lolo I I= I Cl 010 1 � <br /> CURRENT LOCAL AGENCY FACILITY 10 B APPROVED BY NAME PHONE N WITH AREA CODE <br /> Wa <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> IOCAT ON CODE CEM TNACT IL SUPERVISOR-DISTRICT CODE BUSINESS P$N FILED NO <br /> ❑ DATE FILED <br /> 3 b(' aa� 11 <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 ON <br /> FORM A(3-2-88) <br /> �..! DATA PROCESSING COPY �../ <br />