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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME />/^pT- Ch• CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> 4NEAREST CROSS STREET ✓Bar to inNple ❑JARTNERSHE ❑ STATE AGENCY <br /> �fJ( ❑ CORPORATION LF LOCAL AGENCY ❑ FEDERAL AGENCY <br /> t&Amp 6d /pA ❑ INDIVIDUAL ❑ CMNIY AGENCY <br /> ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CITY NAME <br /> PccL A 5336 _ol?-- 2a.Z _v <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bout INDIAN EPA ID # - x of TANK't / <br /> OTHER RESERVATION or El THIS SITE <br /> E] 3 FARM TRUST LANDS <br /> I GAS STATION ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) [. PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Gt NN1 ZlCI Y) A7�C Z`S/7D PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST IRST) PHONE x WITH AREA CODE NIGHTS' NAME(LAST FIRST) <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> - I ,fFry Tom, - na <br /> MAILING Or STREET ADDRESS ✓Box to ind / <br /> icate ❑ ART ERSHIP ❑ STATE-AGENCY <br /> l �pj ❑ CORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> . JDK ❑ INDIVIDGE <br /> UAL ❑ COUN -ANOV <br /> U <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME C� �S J-��y qp�� j/h✓] <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> US <br /> ✓Boa to ATe ❑ PARTNERSHIP ❑ STATE AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> CITY NAME <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. 01 it. III. ❑ <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 x JURISDICTION x AGENCY k FACILITYIDx x of TANKS Bl SITE <br /> FTTJ <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> NC flq <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO ( 2 <br /> 3:Yc5 <br /> CHECK x PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. q <br /> ORM A(3-2-BS) • (\\ <br /> \\ - \ �0 '(b <br />