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rz. �. .;.r. .•.YLP4'.r t�k autA-XITivae. <br /> STATE OF CALIFORMA WATER RESOURCES CON11TOL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �< <br /> r A, COMPLETE THIS FORM FOR EACH FAC ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 1 c <br /> FACI=AME CARE OF ADDRESS INFORMATION <br /> QC b4f rlC'� P Gs IV <br /> ADDRESS ENEARESTSS STREET ✓BOr to irefrale ❑ rATEAGENC <br /> �J WBPoIUTIDV f 0 FEFAL AGENLY❑ ININNGUALCITY NAfIL ZIP CODE SITE PHONE M,WITH AREA CODETYPEOFBUSINESS: ❑ ISTRIBMOR ❑4PROCES50 ✓Box BINDIAN <br /> ❑ 1 GAS STATION ❑3 FARM ER RESERVATION or ❑ 1 N of TANKY <br /> TRUST LANDS 1L,C�.Q AT THIS SITE �— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> 100 <br /> NIGHTS: NAME(UST,FIRST) PHONE q WITH AREA CODE NIGHTS: NAME(UST, IRST) HONE OWITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CAREOFADDRESSINFORMATION <br /> P�AlYllk)6_10&) <br /> MAILINGor STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP C� STATE-AGENCY <br /> ` �� ❑ CORPORATION C�-CpOAr GENCY H FEDERAL-AGENCY <br /> eL ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE a,WITH AREA CODE <br /> F-0rmI <br /> III. TANK OWNER INF RMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE a,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. ❑ 11- III.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> I <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID a It of TANKS at SITE <br /> m — 10 1 C ► i <br /> CURRENT LOCAL AGENDYFACILITY IDI' I - - - APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT BER R <br /> It <br /> APPROVAL DATE PERMIT EXPIRATION DATE <br /> N e <br /> LOCATION <br /> DE CENSUS TRACT�Y SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED NG ❑ DATE D iCCt <br /> CHECK If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIUTN BY: <br /> HIS FORM MUST BE ACCOMPANIED BYAT LEAST(11 OR MORE TANK PERMIT FORM '8'APPLICATION(SJ UNLESS THIS IS A CHANGE OF SITE INFORMATIO LY. t <br /> M A(3-R! '✓ <br /> `/ DATA PROCESSING COPY ✓ <br />