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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> :. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE «,.o ,a <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT V CLOSED SITE r <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> fRANKLIO UiGH c <br /> AD15RESS / NEAREST CROSS Sj ✓B inf.le 0 PARTNERSHIP C STATE AGEN <br /> J00 4) ro oo r Y n /F1 P QL�DAPOMTION 0 LOCAL AGENCY C FEDERAL AGENCY <br /> {cLz--�� l/ l ❑ INDIVIDUAL C COUNNAGENCY <br /> CITY NAME STATE SITE PHONE N.WITH AREA CODE <br /> �' CA 0 C <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> SE <br /> ❑ 1 GAS STATIpN ❑ 3 FARM OTHEq TRUST LANDS VATION D' ❑ N w AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE- <br /> Gorp__ ao 4 <br /> NIGHTS NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME D CARE OF ADDRESS INFORMATION <br /> S �, •e Scl� <br /> MAILING or STREET ADDRESS ✓Sarno inCicale C PARTNERSHIP 0 STATE-AGENCY <br /> '1 /CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> A� I 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATEZIP CODE 05 PHONE p,WITH AREA CLOG <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S a Ph <br /> MAILING or STREET ADDRESSIt ✓Baz W intlicale 0 PARTNERSHIP C STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ IL ❑ III. ❑ i <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# AGENCY# FACILITY ID# #of TANKS BI SITE <br /> l 7 T DO © <br /> CURRENT LOCAL ENCY FACILITYD N APPROVED BY NAME PHONE N WITH AREA CODE <br /> OW <br /> PERMIT NUMBER 3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATICNCODE :PERMIT <br /> SUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a3` � a YES ❑ NO E] /, <br /> CHECK N AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <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 /> � ►�� DATA PROCESSING COPY `r/w/ <br />