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STATE OF CALIFORN('A WATER RESOURCES CONTROL BOARD e` <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> ( <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMaLULY 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 /> FACILITY/SITE NAME CAREOFADDRESS INFORMATION <br /> ADDRESS NEARES{TL—ROSS�S/TIIE�E�T ✓ gilOrlk 0 PARAFRSHP 0 UATEAGDO <br /> IV, ( G(IAIt �vll w'6 TDN ❑ LOCALAGEICY 0 FEDEIULAGDICY <br /> ❑ IIDMGUxI ❑ COINfY#GBICI <br /> CITY NAME ' V STATE ZIP CODE SITE PHO E N,WITH AREA CODE <br /> cA 5 a09 33 -0790 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p fTANwS <br /> ElI GAS STATION ❑ 3 FARM EqESE <br /> OTHER TRUSTYLANDS of <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> wAdemine'l 1&4- a09 33Y- O? O <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE P,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (Mb§T BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT I ZIPCODE PHONE M,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> g1ECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBBB SHOULD MUSED FOR BOTH LEGAL N TIFICATION AND BILLING: I. ❑ IL ❑ 111. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B k <br /> OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY E JURISDICTION R AGENCY N FACILITY ID N M of TANKS N SITE <br /> ajo = = 10 10 1 / 1:3]5 O 0 10 10 <br /> CURRENT LOCA4 AGENCY FACILITYIIF APPROVED BY NAME PHONE N WITH AREA CODE <br /> fl I <br /> PERMIT NUUMBBBEER L!// PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> E CE'S.3 - ILEO BUPERVISOR�T110 CODE BUSINE88 ES❑ED NG ❑ D� 17� Yk PERMIT ZAYOUNTT WRICHA3RDS AMOUNT FEE CODE RECEIPT N 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) <br /> J <br />