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STATE OF CALIFORNS WATER RESOURCES CONTRO BOARD V •"i ''. <br /> f_ • 'A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM I �) Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE lili�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TJE� I-i <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (/ -4 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) OD <br /> W <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> vak, N U/a <br /> ADDRESS If NEAREST CROSS STREET ✓sumrtiale 0 PARINERS11P 0 STATE AGENO <br /> Oro A <br /> ❑ CDR'OFAMN 0 WCALAGE10 Cl FEDERAL AGEIC <br /> V 0 '!NOMOWL 0 CGUNIYAGENC' <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA 9S <br /> 2.0!5 —y6 -173,0s,— <br /> TYPE <br /> 305— <br /> TYPE OF BUSINESS: ❑ 2 OImmur(OR ❑ PROCESSOR ✓BO%if INDIAN EPA 10 % <br /> RESERVATION or #of TANK s <br /> ❑ I GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE /7 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 2019 <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> 2o9 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> �/allr wN �✓a sr gNc <br /> MAILINGor STgEET ApORE55 ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> DX 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME, STATE STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 7oc l.j e 4 s2� 10 - g3aS <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Io indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x,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. ❑ IL 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY , q,;� Q <br /> COUNTY# JURISDICTION It AGENCY# FAQLJTV4Q4 If of TANKS at SITE <br /> D d 1 o <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE It WITH AREA CODE <br /> Lc� 20 A'1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �l, 11 <br /> ( <br /> LOCATION CODE CENSUS TRACT 4 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED --- <br /> I <br /> / <br /> ,23 . O D 25 YES NO � 7/1-t/51 P.. <br /> CHECK 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Al BY: '^ •) 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-BB) Y. <br /> '� � DATA PROCESSING COPY <br />