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STATE OF CALIFORNI* WATER RESOURCES CONTRdCBOARD '"'` ' <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHCILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT Er 5 CHANGE OF INFORMATION ❑ 7 PERMANE CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I.FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> FAGUTY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bubifoo D PAMM30W D SrATE#(;DO <br /> O� ��yafiDN ❑ WgL44II90 ❑ F®BA416130 <br /> 'AEWOU ❑ I%Ym4asIC/ <br /> CITY NAME STATE ZIP CODE SITE PHONE 11,WITH AREA CODE <br /> CA a D 6a69 3& - aG a- <br /> R <br /> TYPE OF BUSINESS: 2 IIUTOR 4 PROCESSOR ✓Bos B INDIAN EPA ID N _ W TAWS❑ I GASSTATON ❑FvVIFARA ❑5 OTHER TRUST LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(UST,FIRST) PHONE N WITH AREA CODE DAY& NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> i�'r W i vl t310 -7 a 2__. <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a STIR ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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 WNN:N ASM AOOIRSS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED ,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION S AGENCY S FA S of TANKS at SITE " <br /> —<b 10DOo <br /> CURRENT LOC NCY FACILITY ID F APPROVED BY NAME PHONE P WITH MEA CODE <br /> 6 <br /> PERM"MUMBE PERYR DAT! PERMIT EXPIRATION DATE <br /> LOCA N CODE CENWB TRACT• SUPERV180R-DMTRICT CODE BUSINESS PLAN❑MUD NO �d <br /> �3 . CTYE <br /> CHECK f PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY• <br /> TMS 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(S-2-BSI �, <br />