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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD SI <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT Eerl CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE L.f <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Swe <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CW <br /> FACWTY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> O/ <br /> ADDRESS NEAREST CROITTe ✓Bp bIK9b C pNA1NElEw C STATE AGM <br /> (7 r f / � t�IORtTIdI ❑ IGfJLAKe ❑ RTAW-,IGENLY <br /> 4 ❑/f1OrvVNW ❑ �{RfY-,ViENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> �S Ca /oma CA <br /> TYPE U5INESS: 2 OLSIRBIJIINi q SSOR ✓Boa d INDIAN EPA ID w <br /> STATION 3 FARM 5 OTHER RESERVATION or C AC Cba y 7,y'(D`( a rANIcN <br /> TRUST LANDS �: AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE w WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LOST.FIRST) PHONE N WITH AREA CODE <br /> eL(R✓Br a✓� (. .. <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING er STREET ADDRESS ✓ s to indicate C PARTNERSHIP C STATE-AGENCY <br /> CORPORATION Cl LOCAL-AGENCY C FEDERAL-AGENCY <br /> /'77/ C INDIVIDUAL C COUNTY-AGENCY <br /> CIN NAME L hSTATE r� ZIP CODE PHONE N.WITH AREA CODE <br />{ T / c H 5.101 _5, <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f2 t( <br /> MAILING or STREET ADDRESS ✓ •to,ndcale Cl PARTNERSHIP C STATE-AGENCY <br /> (( N( CORPORATION Cl LOCAL-AGENCY Cl FEOERAL-AGENCY <br /> C INDIVIDUAL C 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. 11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION IF AGENCY B. FACILITY ID R If of TANKS at SITE <br /> Uij FTTI lolo Idly= Eol o o i <br /> IdTFUIENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 4_ <br /> P ROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> N CODE CENSUS TRACT N�FY1I SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> a3 3 Y�lp YES ❑ NO ❑ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST UI OR MORE TANK PERMIT FORM 'B'APPUCATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) '` / <br /> 3 _ _ � V DATA PROCESSING COPY low <br />