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�J <br /> STATE OF CALIFORNIJ �/ WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® to <br /> /'F COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1:11 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> U Co. T1?� <br /> ADDRE A NEAREST CROSS STREET ✓ ,fa neuale ❑ PAIUNEBSHIP Cl STATE-AGENCY <br /> / /'� Q CT' WIIVIDUkIDN ❑ LOCAL AGENCY Cl FEDE11Al-AGENCY <br /> /'� r ❑ INDNIDUAI ❑ C/JUNIYAGDIp <br /> CITY NAME STATE ZIP Q���� yT�HONE p,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ @ DISTRIBUTOR ❑ 4 P LESSOR ✓Box if INDIAN EPA ID a �(f C N of TANK'S <br /> RESERVATION or ❑ tt—Kul— AT THIS SITE <br /> F-11 G45 STATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Sl' ao ' 3 !o <br /> NIGHTS'. NAME(LAST,FIRS—T^ PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a I Yom/ <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGo REETADORESS R///JJJ / ✓Boz In intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / /_ Kl �0 QV' ii/ ❑ CO ORATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (rJ LSIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME — STATL..� ZIP CODE P L �WITH A3 CODE <br /> /olff <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> as Qr v V-e— <br /> MAILINGarSTREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. IL ❑ If. ❑ <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 N JURISDICTION# AGENCY M FACILITY ID K N of TANKS at SITE <br /> CURRENT L Cpl.AGENCY FACILITY ID# APPRO D Y NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUSTRACT# SUP VISOR-DISTRICT CODE BUSINES`PUN FRED NO ❑ DATE/OILED <br /> p ! 032 <br /> CHECK# 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 ONLY. <br /> FORM A(3-2-98) —�- <br /> *mw. DATA PROCESSING COPY wow <br />