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• r oT� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDzE <br /> FORM 'A': " <br /> UNDERGROUND STORAGE TANK PROGRAM =" �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> o� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION f�f7 PERMANE LOSED SITE �{ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> (711_0- , <br /> ADDRESS I NEAREST CROSS STREET ✓Bar to in Ix ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Z}3 Y ' 11 I1 ❑ TION Cl LOCAL AGENCY ❑ FEDERAL AGENCY <br /> d r d OIVIOUAL ❑ LOCAL AAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> C CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUT R ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID If <br /> RESERVATION or #M TAMC# <br /> ❑ t GASSTATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ 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 /> T L ,a 3(0 - 15 <br /> NIGHTS: NAME ILA ,FIRST) PH E#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE At WITH AREA CODE <br /> Sa wv_- _ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME }- CARE OF ADDRESS INFORMATION <br /> M r S, v r�cL. D,-) (J� <br /> MAILINGorSTREETADDRESS /X+ ✓Box to iod,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S G U ❑ C <br /> PORATION ElLOCAL-AGENCYElFEDERAL-AGENCY <br /> 5 ,0 DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STFA ZIP CODE PHONE#,WITH AREA CODE <br /> C /�LJJ <br /> III. TANK OWNER INFOR ATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME p CARE OF ADDRESS INFORMATION <br /> J <br /> MAILING or S BEET ADDRE B -/Box tolntlicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> 3 DDI- 1 ° 0000 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> ODE CE�USTRACT# SUPERVISOR-STRICT CODE BUSINESS,.PSN FILED NO <br /> D� ILED ��7X2 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: �/CJ <br /> 1. <br /> L J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 MORE TANK PERMIT FORM 'B'APPLICATION(S), UN IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />