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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> Al <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE 4A! FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONEl 7 PERM CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0 N <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> FACILITY/SIT NAME ` CARE OFA KESS INFORMATION <br /> ADDRESS N NST CR�1OOSS T ✓ RaIEl PRNEASNIP ❑ STATEAGENCY <br /> POdTON <br /> C LOCAL AG949 C FEDEPALAGENCY <br /> ❑ INpNIpUAL C COUNTYAGENCY <br /> CITY NAME 0 , SWE ZIP CODE�O SITE PM NE M,WITH AREA CODE <br /> TYPE OF BUSINESS: A01 CA lr2 _o7, M-1-067 <br /> ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID 0 k of TANK'Y <br /> ❑ i GASSTATION ❑ 3 FARM V 5 OTHER TRUST LANDS RESERVATION of ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FIRST) / ' PHONE p WITH AREA CODE DAYS: NA (LAST.FIRST) PHS/4y1TH AREA CODE <br /> 1 .FAL <br /> NIGHTS'. NAME(LAST.FIRST) PHOrE WITH AREA COD NIGH11 T ME(LAST,FIRST) PHONEITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) d(' <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING; BT EET ADDRESS ✓Box to indicate C PARTNERSHIP Cl STATE-AGENCY <br /> C CORPORATION C LOCALAGENCYC FEDERAL-AGENCY <br /> Cl INDIVIDUAL C 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 /> 5 1A <br /> MAILING 0,S REET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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. ❑ Ill.❑ <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 B JURISDICTION R AGENCY R FAS',ILIf1'ID R N of TANKS at SITE <br /> m G '0 1 1 1 1 1 DU 1 C) I I L <br /> CURRENT LOCAL AGENCY FACILITY 10 M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> E CENSUS TRA T SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATES FILED <br /> �rJO . ! YES � NO/,o' &q-PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> tx�, FORM A(3-2-88) — <br /> \VI\Y/ tow DATA PROCESSING COPY <br /> `.aI <br />