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STATE OF CALIFORNIP WATER RESOURCES CONTROAOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ' 5 CHANGE OF INFORMATION ❑ 7 4NENTLY CLOSED E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITYISITEENAME { CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓GavbiNh@ 0 PAWNEFSHIP 0 FATEAGENCY <br /> 0 COWORATION 0 LDCAFAGENCY 0 FEDEML AGENCY <br /> 2 00 SIX ✓7 j'� 'l(Y�CiC- 0 INDN�DWL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> r-e-e Co w, CAS -?Fll2 0129(, <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or ❑ Nof TANK'F <br /> ❑ i GAS STATION [-] 3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) ,.n PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Q�Uc CL `J-I`. -G 2cl(- <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Cf5LAFAA <br /> MAILING or STREET ADDRESS ✓80x to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> L7X ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE if,WITH AREA CODE <br /> t-Pn"C& ro.4 �1'�.Z3 z 2_0. 96 <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5%w P <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ if. 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 M JURISDICTION R AGENCY B FAC ILITY ID k N of TANKS tl SITE <br /> " <br /> 3 � Z <br /> RENT LOCAL AGENCY FA�T1ILITY ID M " APPROVED BY NAME PHONE N WITH AREA CODE <br /> _ JU C1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N BUPERVISOR•DIBTAICT CODE BUSINESS PLAN FILED DATE FILED ) <br /> c'— YES NO ❑ /Q Tr//- <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 INFORMATIONON . <br /> ORM A(3-2-88) 0 0 <br />