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. ov <br /> Ze P`iuiie't�\ <br /> WATER RESOURCES CONTROL BOARD <br /> STATE OF CALIFORNI ` ' a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM e <br /> SITE ""°113 <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '� ' �:/ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> Ulf CHANGE OF INFORMATION ❑7 PERMANE TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ <br /> 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BEDCOMPDLETEDRESS RMArION <br /> FACILITY/SIT NAME l U 7ARE3IV <br /> ✓Box toi�bgak 0 PAMNMIIP 0 5AiFAGENGV <br /> V Y✓ — NEAR ST OR SS ClWgPOPA <br /> ` IION 0 LOCALAGENCY CEML GENIX <br /> ADDRESS ,<,/({ • 0 INDNIWAL 0 COUNTY AGENCf <br /> STATE ZIP CEDEjA. SITE PH NE k,WITH AREA LADE(—/� <br /> CITY NAMES • CA JI <br /> C/�/" EPA ID q AT THIS SITE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PflOCESSOR ESERVATION or ❑ / AT THIS SITE <br /> ❑ I GAS STATION ❑3 FARM <br /> OTHER TRUST LANDS N <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMS: NAM Y CONTACT PERSON(SECONDARY) <br /> pFl NE q WITH AREA CODE <br /> D YS: NAME(LAST,FIRST P ONE M WITH AREA CO�DyE DAYS: N?A1 (LAST•FIRST] <br /> b �L/ `zS PAT PH E IIWITH AREA CODE <br /> NIGHTS: NAPE(LAST,FIRST) PHO E q WITH AREA CODE NIGHTS E(LAST,FIRST ^ <br /> A � A N <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OFA DRESS INFORMATION <br /> NAM <br /> DSTATE-AGENCY <br /> ✓Box to indicate ❑ PARTNERBHIP F DER L-A NCV <br /> MAILI G o,STREET ADDRESS / n _/ 0 CORPORATION 0LOCAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGEN PHONE WITH AREA CODE <br /> r Ll STATE ZIP CODE q�qI <br /> CITY NAME �1A ��'� /"' I <br /> III. TANK OWNER INFORMATION & ADDRESS .— (MUST BE COOMPPLETED)CARE OF RESS ATON <br /> NAME )12 <br /> ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY <br /> DFEDERAL-AGENCY <br /> /1 v 0 INDIDUAL 0 COUNTY-AGENCY <br /> A -STATE ZIP CODE PHONE q, ,IATH AREA CODE <br /> CITY NAME ), ✓� <br /> IF•f"F v� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CXECK ONE(1)BOL[INDICATING WNICN ABOYE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 111•❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M <br /> AGENCY M FACILITY IDM M o1 TANKS at SITE <br /> UD r = U = <br /> APP V D Y E ONE M WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> PR <br /> L/"R_Z� PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> BUSINESS PLAN FILED DATE FI ED <br /> � SUPERVISOR-DISTRICT CODE NO <br /> LOCATION CODE CENSUS 7NIICTj� C�/!• YES <br /> FEE CODE RECEIPT If BY: <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />