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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION / PERM CLOSE TE N <br /> ONE ITEM <br /> E12 INTERIM PERMIT ❑ 4 AMENDED PERMIT TEMPORARY SITE CLOSURE 4 <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) O <br /> FA ILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDNEAREST C OSS STREET ✓gnrl�agirak ❑ PApI49WIIP ❑ STATEAGENCY <br /> RESS <br /> a ;�- I O G` U/ X1.6017011PDR0011 ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDWL El WUNTYAGENCY <br /> CITY NAME STATE ZIP CODES E PHONE X,WITH AREA CODE <br /> CA 0 S 0 /G G 8r 9�i <br /> TYPE OF BUSINESS: 2DISTRISUTOR 4PROCESSOR ✓Box IT INDIAN EPA IDX �y.�� <br /> E] 1 GA$$TATION ❑ 3 FARM HEfl TRUST LANDS o1 ElAw AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> R b n so - <br /> NIGHTS- NAME KVjjr,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boxloindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE X,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 ❑ IS.❑ <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 X JURISDICTION X AGENCY X FACILITY ID# #of TANKS at SITE <br /> 60 / l D l (IODA <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE X WITH AREA CODE <br /> I <br /> PERMIT NUMBER ` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN$U /RACTD SUPERVISOR-DISIRRICT CODE BUSINESS PUN FILED ❑ DA E FILED <br /> YES NO pc JY <br /> CHECK X 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 /> DATA PROCESSING COPY ,r.► 1 <br /> �A <br />