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1­1— .- YTAV - .-... .. <br /> STATE OF CALIFORNI/r WATER RESOURCES CONTROL-BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - <br /> CCOMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Fil 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> V <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /✓C U <br /> ADDRESS �/ NEAREST CROSS STREET ✓Box 10mule ❑ PARTNERSHIP ❑ STATEAGENCY <br /> 8 /5O E71 00MC10 ❑ IND DUALION O CORN AEN CY ❑ GEML AGENCY <br /> CITY NAME STAT 21 CODE SITE PHONE It,WITH AREA CODE <br /> 04v^b CA a t <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or #of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM El5 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 If WITH AREA CODE <br /> L0,,rwYan) P{lf l li - -1)61to <br /> NIGHTS'. NAME(LAST FIRST) PHONE N WITVREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or TREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑/CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> cKkbelk — -700 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION <br /> P, QS <br /> MAILING or STREET ADDRESS ✓Box to md,oale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 1.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. ❑ 11. k2, ill. ❑ <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# JURISDICTION R AGENCY R FACILITY ID It Is of TANKS at SITE <br /> 1 1 11151 ,1131 <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE 0 WITH AREA 60DE <br /> 441-to 8 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT,7 CODE CENSUS TRRAACyT�# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> / ,Z 3,W 3 z�'- YES F] NO � Zg <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 011�5 <br /> FORM A(3-2 SO <br /> DATA PROCESSING COPY , <br />