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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o <br /> n� <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE CaL sOR P <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ly 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> pNE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Suloirdiate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> t ❑ IXIRPDRATIDN ❑ LOC+LL-AGENCf ❑ FEDERAL-AGENCY <br /> l7/UO 5' c� Course ❑ 1�ouu ❑ COUNnMGENa <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE . <br /> CA125330 .?c'' m- 090 <br /> TYPE OF BUSINESS" ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 6 INDIAN EPA ID# #Of TANK's <br /> El GM STATION L] 3 FARM 5 OTHER RESERVATION or <br /> ❑ TRUST LANDS ❑ 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#WITH AREA CODE <br /> NIGHTS: NAME(LUST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> E'9 � N t;. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> r7lOb d���N ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> (�, o 3 3 p <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> k, ayc N r <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> d_ ax 271 ❑ INDIVIDUAL_ ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE <br /> 64 95'33 0 <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: L ❑ I. ❑ ,LIV <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,JS TRUE AND CORRECT, <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION A AGENCY# FACILITY IDA EE <br /> #of TANKS n SITE <br /> EI 1 i-11 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> C Ap.CAK P r7 <br /> PERMIT NUMBER PERMIT APP OVAL DATE -�A., PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT DE BUSINESS PLAN FILED DATE FILED <br /> \ I , S b 3� YES ❑ NO ❑ ` q <br /> CHECK# PERMIT AMOUNT rCHARGE AMOUNT FEE CODE RECEIPT N B <br /> THIS FORM MUSTPE ACCOMPANIED BY AT LEAST.(1)ORRE TANK PER FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �. <br /> FORM A(3-2-9e) 9 <br />