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5"`�uoti '4 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD { <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC "ACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P TLYCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME, <br /> Dp T or, 7/tAh(S <br /> NEAREST CROSS STREET ✓BoRPMab ❑ PARMBGN STATE <br /> ADDRESS I [ITOgPOMTION ❑ LOCAL-AGENCY ROERAL-AGENCY <br /> 3 ( Z S , LCL N(.O L n1 ❑ INDMWAL ❑ DUMAS'-- <br /> CITY NAME STATE ZIP CODE_�� SITE PHONE pWITH AREA CDEO <br /> S w CA J! <br /> TYPEOFBUSINESS: 2 DISTRIBUTOR ESSOR ✓Box II INDIAN EPA ID p NoI TANMs <br /> ❑ E]4,1 RESERVATION or AT THIS SITE <br /> ❑ I GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> PHONE p WITH AREA CODE <br /> 0- �(i�t 209— 3/ - 39 -73 It <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(TT,FIRST) <br /> 51-1'n�� 4 <br /> 11.FNAME <br /> PERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> /� n � Y/S TO . J <br /> G or STB/EET ADDRESS,d ,V /V ✓Bov to intlicate ❑ PARTNERSHIP STATE-AGENCY <br /> Com/ ❑ CORPORATION III <br /> ❑ FEDERAL-AGENCY <br /> (( <br /> 2- 0 �i / / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> AME STATE ZIP CO D PHONE If.WITH AREA CODE O. <br /> SA-t 2 Am � 7d — <br /> Ill. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to intlimie ❑ PARTNERSHIP ❑ S7ATE-AGENCY <br /> ❑ INDIVIDUAL ❑ Lo NTAGENCCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANTS NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY IDN N o1 TANKS Bt SITE <br /> COUNTYN JURISDICTION <br /> � AOE�� <br /> � % d�� UPU A <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID Z <br /> PERMIT NUMBER ' PERMIT APPROVAL DATE n/2 7Af�PERMIT EXPIRATION DATE <br /> f. d DATE FILED <br /> YES NO <br /> LOCATION CODE <br /> CENSUS T111AC(T�N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDED <br /> D <br /> -13 V D <br /> CNECK M PERMIT AMOUNT <br /> SURCHARGE AMOUNT FEE CODE RECEIPT 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(3-2-88) 0 <br />