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STATE OF CALIFORNW WATER RESOURCES CONTROf-SOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ul f <br /> ST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE •�^"'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERR&NLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME �'` CARE OF ADDRE INFORMATION , <br /> CL FQ r 01 <br /> fl C_ <br /> ADORE S$ ,, • NEAREST CROSS ST ✓ bMiuk D PARTNMW D STATE-AGDO <br /> E • a- Illi V �YI C�J D II�Y1q�YT1 0 tC ftm� FEOEAA,L.ARENLY <br /> CITY NAME /w \ 1 e STATE ZIP CODE� SITE HONE p.WITH AREA CODE D <br /> TYPE OF BUSINESS. ❑ p RIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN EPA ID N 5 h^i <br /> flESERVATION or - � N of TANK'N <br /> ❑ I GAS STATION 3 FARM E' 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME ILAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> F2�rQfA Ca a9 - 3 <br /> NIGHTS: NAME(LAST,FI ) PHO E N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or TREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> El CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or eREET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY E JURISDICTION k AGENCY N FACILITY ID R R of TANKS SI SITE " <br /> m od F 1151 10oa <br /> CURRENT CAL AGEMCX FACILITY 10#-7 <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> gCHECK <br /> R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT♦ SUPERV180R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> OL, YES C3 NO ❑ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> `� FORM A(3-2-881 1 <br />