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TATE OF CALIFORNIA WATER RESOURCES CONTROAARD <br /> )RM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y C ITE F'+ <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD <br /> CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATIpN/K/,( <br /> .( S - &v:- - <br /> ADDRESS / Y NEAREST CROSS STREET ✓Rm0 ❑ PARTNERSHIP ❑ STATE AGENCY <br /> /- x //� T10N ❑ Lox-AGENG ❑ FEDERAL AGENCY <br /> lC (��/ ✓ k— NI ❑ COUNTY AGENCY <br /> CITY NAME > STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> Gobi CA 9 ( !(L <br /> TYPE OF BUSINESS: ❑2,91SWUTOR F-14 PROCESSOR ✓BOx if INDIAN EPA ID N X of TANK'F <br /> RE❑ 1 GASSTATION 3 FARM ❑ 5 OTHER TRUSTTVATION LAND$or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> O -7-- <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME S119- ---7- CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS Box to <br /> (e ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> N DIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box m e 11 PARTNERSHIP [I STATE-AGENCY <br /> ORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> INDIVIDUAL ❑ 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ Ill. ❑ <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 /> COUNTYIN JURISDICTION II AGENCY* FACILITY ID R R of TANKS at SITE <br /> ail I I IL40=1 <br /> CURRENT LOCAL A NCY FACILITY ID M APPROVED BY NAME PHONE Al WITH AREA CODE <br /> A�ffc <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT K SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> C9 <br /> x3 a YES F] NO <br /> ❑ !�Y <br /> CXECKA PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 INFORM\/ACTION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />