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STATE OF CALIFORNI)r WATER RESOURCES CONTRd'ItOARD <br /> A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'Lr o•x� <br /> MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑l AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE TZ-z>-7 <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> FACLITY/ TE NAME CARE OF ADDRESS INFORMATION <br /> l!/ Lj::C� Cli <br /> ADDRESS �' / NEAREST CROSS STREET ✓BPw duN ❑ PABMEIGM ❑ STAIEJiwo <br /> 0 �GL� �' V °o 00RFWT0N 11 13 � ❑ ROBw c <br /> CITY NAME TATE ZIP CODE _ SITE PHHfONE#,WITH AREA CODE <br /> F BUSINESS: ❑ 2 DISRiI ❑4 PROCESSOR ✓Bar B INDIAN EPA ID p <br /> RESERVATION or N of TANK'# <br /> ❑ I GAS STATION ANA ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAM ECARE OF ADDRESS INFORMATION <br /> �1 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - ❑ STATE-AGENCY <br /> C ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY1,7 7w DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> li0` _7_- I kto 156$1' <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE Of ADDRESS INFORMATION <br /> MAIL or STREET ADDRESS ✓Bax to ioEicale ElPARTNERSHIP 13STATE-AGENCY <br /> /�f(/JQO ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL O COUNTY-AGENCY <br /> CITY NA�" STATE ZIP CODE ONE#,WITH AREA CODE <br /> /iC/D.T' G xZs S-LSS <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. ❑ 11.4nIII. ❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N rJURISDICTION N ff AGEN�CY N FACILITY ID N N of TANKS H SITE <br /> CURRENT LOCAL AGENCY FACILITY IO# APPROVED BY NAME PHONE N WITH AREA CODE <br /> G <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE flD f- <br /> YES NO ` Cp <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT I BY ? <br /> 44 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM'B'APPLICATION(S), UNLESS THIS IS A CHANCE OF SITE INFORMATION ONLY. /\C7� <br /> FORM A(3-12W � ` <br />