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4, <br /> STATE OF CALIFORNIA' WATER RESOURCES CONTROrBOARD <br /> r <br /> FORM ' <br /> A':A : UNDERGROUND STORAGE TANK PROGRAM �e <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT Fr5 CHANGE OF INFORMATION ❑ 7 P LOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE Z <br /> Im <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACII-IlleyNAIIIIIE CAREOF TA D FESS INFORMATION <br /> Z <br /> J "Illi <br /> ADDRE' N T ROSS STRED PAROD STAR ALGAENG <br /> CY <br /> [_1 00WOAATION ❑ LOCA_AGENCY <br /> ❑ INDIVIDUAL ❑ COUNIN AGENC <br /> Z <br /> CITY NAME E IP O E P NEa,WTHA CODE/ <br /> cA N�•�/�:R" <br /> ('1)8 <br /> TYPE OF SINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box II INDIAN EPA ID N Xa1TANK's <br /> RESERVATION or AT THIS SITE /�c� <br /> 1 GAS6TATION ❑3 FARM ❑ 50THEFl TRUST LANDS ❑ /� 10 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST. IRST) HONE M WITH AREA CODE DAYS: NA E(LAST,FIRST) PH�Nk WITH AREA CODE <br /> v 364 - Si/'Ib }/s� <br /> N HTS. ME(LAST,FIR ) PHONE N WITH AREA DE NIGHTS: ME(LAST,FIRST) PHOIV N WITH AREA CODE <br /> -r y a O(� Iwr <br /> 11. PROPERTY O NER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 5 !A at-o�v CARE OF ADD ESS INFORMATION <br /> MAILING g( REETAD„D���REESSS ✓Box to indicate 13 PARTNERSHIP 11 STATE-AGENCY <br /> 5 ❑ CORPORATION ❑ LOCAL-AGENCY F DE AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME' STATE ZIP C E PMO E WITH AREA CODE <br /> sA aQA <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED <br /> NAME , p CAREOFA DRESS INFORMATION <br /> AD <br /> MAILN REST ADDRESS /A✓✓�/ax to ind,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> FQ� BYCORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAMEST ZIP C�JDE PHOUF WITH AREA CODE <br /> 4 CY Z /YI <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: 1. 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION If AGENCY M FACILITY ID k if of TANKS at SITE <br /> ® = = I ol 6 l o 0 1,3 <br /> CURRENT LOCAL AG`ENCCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> �l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUP V SDR-DISTRICT CODE BUSINESS PLAN FILED DATE LEO <br /> QW% YES ❑ NO <br /> CNE M PERMRAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-56) <br /> DATA PROCESSING COPY <br />