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STATE OF CALIFORNIA" WATER RESOURCES CONTROL BOARD e• . <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE TLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET PARTNERSHIP 0 STATE-AGENCY <br /> 170 7/ 9. c.�� Gl�C— L YAGRI ❑ wnGac <br /> CITY NAME STATE Zip CODE SITE PHONE N.WITH AREA CODE <br /> Gln�lPn - CA ulc. <br /> TYPE OF BUSINESS: ❑2 OI UTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID N _ t o/TANK'4 <br /> ❑ i GAS STATION FARM ❑ 5 OTHER RESETRUSTYLANDS or ❑ �---- AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> lS11,4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 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 /> s�� z7_ <br /> MAILING or STREET ADDRESS ✓ 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATIOicate N 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME c /� CARE OF ADDRESS INFORMATION <br /> J 1T L <br /> MAILING or STREET ADDRESS ✓ to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. Fp�II. ❑ 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 R JURISDICTION N AGENCY# FACILITY ID N R of TANKS at SITE <br /> CURRENT LOCAL AgPCY�r�Ll�IDP APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER `i '/`/ /1/I'f/PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOLCODECENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHPERMIT 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 /> FORMA(3-2-BB) <br /> DATA PROCESSING COPY <br />