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3 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE I, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION oo ,! to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑(6673 "Y <br /> P�� LV CLOSED SITE <br /> ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1/ a) <br /> na <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) -4 <br /> FACILITY/SITE NAME , CARE OF ADDRESS INFORMATION <br /> Q Sucy <br /> NEAREST CROSS R1EE, ✓3Pbi4NN ❑ PNM <br /> ~ ❑ MsTAtAG <br /> ADDRESS 0 V I N J� vel(e5 (�rl 1L ❑ CR4ilON ❑ LO ❑ fEEE1NLACENC( <br /> ❑ INDMWAI ❑ D <br /> CITY NAME x STATE ZIP CODE SITE PHONEA CODE <br /> Lo-d r CA 9�2-yo <br /> V Box if INDIAN ' <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR El PROCESSOR RESERVATIONON or El <br /> ID N - Fol TANK IS <br /> E] 1 GAS STATION E]3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <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 /> Aee-Ai V It j ►c <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N H AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME (( ' CARE OF ADDRESS INFORMATION <br /> �J <br /> MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl 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 STREET ADDRESS ✓Bax to,rd,.to ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ It. ❑ 111.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F JURISDICTION F AGENCY F FACILITY ID F ao #of TANKS at SITE <br /> ml C� I lo14111sl <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> j�rn�� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> TION CODE CENSUS TRACT# SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> PERMITAMOUNT SURCHARGEAMOUNT FEE CODE RECEIPTM <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 /> ,VAv1 FORM A(3-2-BB) <br /> DATA PROCESSING COPY <br />