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STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM , m <br /> SITE ZFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r"'tkFs <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE r9_c,=oR ,r <br /> MARK ONLY ❑ r NEW PERMIT ❑ 3 RENEWAL PERMIT !❑5 CHANGE OF INFORMATION ❑ PERMANENTLY �SED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> ❑6 TEMPORARY SITE CLOSURE <br /> f. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I b <br /> F Lay/SITE NAME <br /> CARE OF AUDR€SS INFORMATION <br /> ADDRESS <br /> ,s'1/ Q� [��Op NEAREST CROSS STREET ✓ao=In+l�cate ❑ PARTNERSHIP ASWP ❑ STATE,AGENCY <br /> �y _ �y`'Ni y l ❑ 'E tA'I�r ❑ LOCAL aGENG� ❑ FEOEW t AGEkLY <br /> CITY NA - - (� IMOMpUAI ❑ COUNTY-AGENCY <br /> STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> �IAc CA <br /> TYPE OF 9USINESS' ❑2 dISTRIBLITOR 4 PR(}CES$OR ✓Bax if INDIAN EPA ID a <br /> ❑ I GASSTATION ❑3 FARM ❑ 5 OTHER RESERVATION or ❑ If of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAS FIRST) rr PHONE It WITH AREA C DAYS ,rW ILAST,FI <br /> �� r JbnyF�)l PHONE p WITH AREA CODE <br /> y <br /> NIGHTS- ME(LAST,FIRST) HON NWITH AREA CO¢E NIGHTS; NAME(LAST,FIRST)3 PHONE p WIT AREA CODE <br /> II. PROPERTY WNER INFO ATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM � t-.AR OF ADDRESS - RMAT ,I'� / <br /> MAI jVG or STREi=TrESS �✓ <br /> ✓BOX to md,Care ❑ PARTNERSHIP STATE-AGENCY <br /> r1 Q CORPORATION ElLOCAL-AGENCY {] FEDERAL-AGENCY <br /> CAME C/ ❑ INDIYIf)UAL COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWN R INFORM T ON & ADDRESS (MUST BE COMPLETED) <br /> NAME <br /> 0-6 11 ^c ,o CARE QII SS INFORM I N <br /> .ArIL,IING Cr TREET A L% pe) <br /> ✓Sox to no cafie © PARTN RSHIP ❑ <br /> STATE-AENCY <br /> ❑ CORPORATION © LOCAL-AGENCY FEDERAL-AGENCY11 <br /> CITY AME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> r,44 STATE ZIP CODE PHONE it.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATJNG WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ <br /> III. <br /> THIS FORA?HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATI.IRFI <br /> DATC <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID N <br /> — #of TANKS at SITE <br /> � F <br /> CURRENT LOCAL AGENCY FACILITY IDN i APPROVED BY NAME <br /> k02 <br /> 'F 0 ' PHONE N WITH AREA CODE <br /> PERMIT NUMBER (/ PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION OATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE '— <br /> BUSINESS PLAN FILED DA 7E/FIC D <br /> CHECK N__ PERMIT YES ❑ NO <br /> AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT N BY: <br /> THIS FORD MUST BE ACCOMPANIED BY AT LE* <br /> r = <br /> OR MORE TANK PERMIT FORM $ APPLICATION(S),0 <br /> SS THIS IS A CHANGE OF SITE INFORMATION O <br /> i <br />