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nn <br /> STATE OF CALIFORNII� WATER RESOURCES CONTRO OARD <br /> z�: <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILI <br /> TY/SITE, INFORMATION and/or PERMIT APPLICATION ; to <br /> . COMPLETE THIS FORM FOR EACH ACILITY/SITE c'FOR", <br /> 1 NEW PERMIT 3 RENEWAL PERMIT Y5 CHANGE OF INFORMATION E:] 7.9WWAllErLY CLOSED SITE <br /> MARK ONLY F-1 <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST B COMPLETED) <br /> W <br /> FACILITY/SITE NAME (,GL ARE OF ADDRESS INFORMATION <br /> f)l✓7 1 A SlU1® <br /> ADDRESS NEAREST CROSS STREET ✓Bola Mute ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ WRPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> blA Me <br /> ❑ INDIVIDUAL ❑ FAUNT'-AGENCt <br /> CITY NAME 5V STAIA ZIP CODE �� SITE PHO E N=1TH AR AOCOQE <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR d PROCESSOR ✓Box if INDIAN EPA ID k _ #of TANK's X// <br /> 1 GAS STATION 3 FARM RESERVATION or ElpT THIS SITE <br /> 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: ME(LAST,FIRST) N' PHONE M WITH AREA COE DAYS. NAME(IAST,FIRST) PHONE 4 WITH AREA COD <br /> 61 u� X 26 <br /> NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(L T,FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> DD S O V 0 <br /> �w <br /> MAILING or STREET A1k a /AST ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> 1 l ION [IFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCYCITU NAMEGfv ♦Dqq`I V/ STATE ZIPCO-7 <br /> P7W p.WITH AREA jO; <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) Z6 S(7/ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N.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. 1pr III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND0.CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k AGENCY* FACILITY ID# k of TANKS BI SITE <br /> 39 00 / ov6 10101, <br /> CURRENT LOCAL AGENCY FACILITY ID k h APPROVED BY NAME PHONE k WITH AREA CODE <br /> V <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ODE CENSUS'TJRACT k SUPERVISOR- STRICT CODE BUSINESS PLAN FILED DATE FILED '7 <br /> aZ YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <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 /> FOR y1 A(3-2-8el <br /> �2 /•ll DATA PROCESSING COPY �� <br />