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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEa^«-��^ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYF"a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 �4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Y/ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> • <br /> /fes, 3-o/ n s- <br /> ADDRESS NEAREST CROSS STREET ✓Bwb- ❑ PMTNPMP ClSTATEAWIC/ <br /> // o H 9 ❑ MMN ❑ LOCk AGEXLY ❑ FB1ER11L.AGM <br /> INDYIDIAL ❑ MUICYAGENLY <br /> CITY NAME _ STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA 9S U u�- <br /> TYPE OF BUSINESS: ❑3'prjIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS VATION or❑ /� / F AI TANKF <br /> ✓( L C--- 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 N WITH AREA CODE <br /> NI <br /> __ w. &6 fn Jc��l n 5 <br /> GHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to e ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> A ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> S <1- ,�} <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME S q ✓� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET AbDRESS ✓6c nd,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S /I Cl RPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> H INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 5,1141— <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. II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 11 JURISDICTION 11 AGENCY N FACILITY ID N R of TANKS at SITE <br /> UE = -1 I ,a 0 o I v I i <br /> CURRENT LOCAL AGENCX FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 313 3 d'�� YES E] NO —/�- <br /> / CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY:oes <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 /> FORMA(3-2-1113) <br /> DATA PROCESSING COPY <br />