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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ""`''T' <br /> W <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 44, ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE � "-"--1 <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P ENTLV CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ;y <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME Q� f / CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET o[Wind- ❑ PARTNERSHIP ❑ STATE AGENCY N <br /> C A /i o�/n COHPORAiION ❑ LOCALAGENCY ❑ FEDERALAGENCY CM <br /> Q Q T J Gl V, INpIVIpUAL ❑ LOUNtt AGEING! coCITY NAME STATE ZIP(]QDE - / SITE P ONE p,WITH A A 0 A W <br /> CA 45 Y <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID u It of TANK'F <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TTRUSTVLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. N ME(LAST,FIRST) PHONE p WITH AREA CODE DAYS' NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> 56f;7&7-3Mrol kko 11i-Ar c yir—�27�j66 <br /> NIGHTS: N (LAST, ST) w_ PHONE k WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> SA/VEL <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C A I�R� A rx u K,1, rjj IMP IVI S`-6 <br /> MAILING or STREET AD $1S /� I(,, .1 ./J.�,�_ C }Iy ox to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1 UNS•�I�F IAr.` `•'�I/V ❑ NDIVIDUALION ❑ COUNTY AGENCY Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ,•. �� STATS ZIPC�E /// / PHONE1.WI <br />