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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD l <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ / NEW PERMIT ❑3 RENEWAL PERMIT grC.ANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SITE <br /> ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE F 3 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE� NA , /� CARE OF ADDRESS INFORMATION <br /> ADDRESS / /� ^ / NEAREST CROSS STREET ✓Bwbiviak ❑ PAAWJ&P ❑ STATE-AGENLY <br /> l I <br /> lei nom•)( /X�Y//C,(-/-L_/ C�J,l/ eC <br /> ;�o <br /> ❑ Cl>IVIDUA GN ❑ LOGLAGENLY ❑ FEDEIW.-AGENLY <br /> Cl CONIWAI ❑ LOA1V-AGENCY <br /> CITY NAME S� � I� STATE <br /> CA Zo� CaPHONE N.WITH AREA CODE <br /> 57Q <br /> TYPE OF BUSINESS: ❑ p TRIL/BUTOfl 4 PROCESSOR ✓Box it INDIAN EPA ID # 3 <br /> RESERVATION or #of TANK's <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 1• A ' CARE OF ADDRESS INFORMATION <br /> MAILINGmSTREET ADDRESS (� �[ ✓Box to indicate Cl PARTNERSHIP ClSTATE-AGENCY <br /> E3 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ��� + V ' 1 STAT ZIP CO) 0 PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S GC s <br /> MAILING o,STREET ADDRESS %/Box to indicate ❑ 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: I. ❑ it. 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# JURISDICTION# AGENCY# FACILITY ID# Is of TANKS at SITE <br /> 60110010101 / 1 <br /> CURREN AGENCY FACILITY APPROVED BY NAME - AH ITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a'J . -3 3 a YES ❑ NO <br /> CHECK If 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 <br /> FORM A(3-2-88) J <br /> .� DATA PROCESSING COPY :� <br />