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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD <br /> Y�. a <br /> FORM NA': " <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> L <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLO SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> r ss arosso <br /> 3 <br /> ADD ESS x�/�� NEAREST CROSS STREET ✓BmbialaV 0 PAATNFRRIIP 0 STATE AGENCY <br /> /� y \ 0 �AAnON 1:1 LOCAL AGENCY <br /> r 7 ACkN <br /> ❑ INDMDUAL 0 COIINTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> G CA <br /> TYPE OF BUSINESS: ❑ 2 DIST UiOA ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N N� ' � •of TANK'4 <br /> RESERVATION or ❑ YI./(�y�-� AT THIS SITE 0 <br /> ❑ I UASSTATION 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 /> n o.sso t4lbert Coq 3 -3 a:. <br /> NIGHTS'. NAME(LAST,FIRST) �� p PHONE ITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> W/F__ <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING JSTREET ADDRESS ✓Box to ietlicate D PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or SThEET ADDRESS ✓Box to inCicate D PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 R JURISDICTION 0 AGENCY S FACILITY ID M R o1 TANKS at SITE <br /> lalalil,61= = Obl <br /> CURRE CAL A NCY FACyJTY ID APPROVED BY NAME PHONE P WITH AREA CODE <br /> PERMIT NUMBER J( •3 PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT COOK BUSINESS PLAN FILED DA F1 O <br /> �l Q0 . `� N� YES NO <br /> CHECK If PERMIT AMOUNT(/` SURCHARGE AMOUNT FEE CODE RECEIPT4 BY: <br /> Y ■�`I /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(3-2-88) S <br />