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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s` + '` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �'" <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� Z <br /> /'1` I C) <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A��o�x�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C OSED SITE H+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE v <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OD <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> ADDRESS / LN�RESTS�TR��T ✓Bc.:tOWo, ❑ PAUNEASHIP ❑ STATE AGENCY <br /> Td CDBP ❑ LOCAL-AGENCY ❑ FEOEPALAGENCY <br /> IDUAL ❑ COIINFYAGENCY <br /> CITY NAME ZIP C E SIT PHONE p,WITH AREA COOS S Cyj� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUT ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ Ri�'�/ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /v9Yhel <br /> P3 <br /> ) PHONE S-3/95 <br /> NIGHTS: NAME(LAST,FIR N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CZOCARE OF ADDRESS INFORMATION <br /> WV 444 <br /> MAILING or STREET ADDRESS 119 1 ^ ^ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 'flJ�/ I] CORPORATION 13LOCAL-AGENCY El FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 7G <br /> Ill. TANK OWNER INFORPATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS '/Box to indl 11 PARTNERSHIP ❑ STATEAGENCY <br /> 5 71CO TION Cl LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP COD PHONE I.WITH AREA CODE <br /> 3? 3l S 5 <br /> IV. LEGAL NOTIFICATION D BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ If.❑ <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 K JURISDICTION Ar AGENCY R FACILITY ID 1 W of TANKS at SITE <br /> m oo IdN I c) i <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> F_5r <br /> PERMIT NUMBER PERMIT APPROVALD PERMIT EXPIRATION DATE <br /> a <br /> L <br /> CATION C CENSUSTRACT M SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED�3 YES ❑ NO <br /> ECK R PERMIT AMOUNT SURCHARGE AMO' NT FEE CODE RECEIPT F f B <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 /> FORM A(3-2-88) S <br /> ../ DATA PROCESSING COPY logo <br />