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oT . <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ma <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> e1l,FORi'P <br /> COMPLETE THIS FORM FOR EACH FA !Y/SITE <br /> I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> PAO'L'TY'S'TENAME CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓Boob id✓i% ❑ PAAINASIIP ❑ SIATE A3 <br /> - ❑ GBYATON ❑ LOCALAGDO ❑ FRIBIALAGE'1LY <br /> / ❑ INBMDUAL ❑ cwm,AmcY STATE ZIP CODE SITEPHONE N.WITH AREA CODECA 9Sav Z�c- - S 72 DISTRIBUTOR 1 PROCESSOR ✓Box i11NDIAN EPA IDN %of TANICs <br /> RESERVATION or AT THIS SITE <br /> 3 FARM ❑ 5 OTHER TRUST(ANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ILAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> lx'0 01f-Y6 -S3 sa 1--QNIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sa';,..e I S cr •A-Q- <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME L Q CARE OF ADDRESS INFORMATION <br /> - <br /> MAILING or STREET ADDRESS ✓Box la irltllcale 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> rl yQ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITV NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a Rs T� <br /> MAILING ar STREET ADDRESS ✓Box lomdioale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ar if. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION B AGENCY B FACILITY ID S If of TANKS at SITE <br /> q O D / �' r0 1 C/ C) 10 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N R'RH AREA CODE <br /> 0/ 7-/!5 // <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> rLOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 -31 � YES NO S <br /> KF 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 ONLY./^ <br /> FORM A(3-2-88) <br /> W s 3( `� <br />