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STATE OF CALIFORNI WATER RESOURCES CONTRONOARD /s`•"`cc.,:`•,-'e <br /> FORM 'A': A <br /> S'-r UNDERGROUND STORAGE TANK PROGRAM <br /> FA INF INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE F cy® 10 <br /> ORN R <br /> MARK ONLY ❑ ( NEW PERMIT 0 3 RENEWAL PERMIT <br /> ONE ITEM 6 CHANGE OF INFORMATION T pERMANE DSITE }.a <br /> 2 INTERIM PERMIT 0 q AMENDED PERMIT <br /> 6 TEMPORARY SITE CLOSURE IV <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> I I - CARE OF OGRESS INFORMATION 1 '- <br /> ADDRESS ( 111 Y'1 — dnN 0 i'1'l✓F� Or-1 di <br /> NEAREST CROSS STREET ✓Sam ddias —❑ P INERSHIP <br /> SUoGA11'1 ��fY/ TQrr�O— SI�t�Ct ❑ CORPOnnTON 1� ❑ FSTATE AGENCY <br /> EGERLAGEN <br /> CITY NAME ❑ INOIWDOAL I] �TAGMO ❑ FEOEPALAGENCY <br /> STATE COUNTYAGENCY <br /> f by ZIP ODE SITE PHONE#.WITH AREA CODE <br /> TYPE OF BUSINESS: 0 2 DISTRIBUTOR 0 q PROCESSOR ✓Box if INDIAN EPA ID xA 5 a I V �0 Sl 933 <br /> Fl 1 GAS STATION [] 3 FARM �HER RESERVATION orTRUST LANDS ❑ If of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE D <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS: NAME(LAS RST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> C PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS. NAME(LAST,FIRST)'(L PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> O (T - I / �� CA F A DRESS IIJFORMATION O�� <br /> MAILING or STREE ADDRESS \(/(�.'�(, 11 'y�1/)` <br /> a5ENCn� ✓Boz to intlicate ❑ ENCY <br /> P gTN;ALERBHIP 13 <br /> Y <br /> I l �I ❑ INDIVIDUAEl LOT <br /> L Cl <br /> COUN AGENCY AGENCY 0 LOCAL AGENCY ❑ FEGERALTATE GAGENCY <br /> CITY N E <br /> ZIP C E PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED ��� <br /> RNAME .�, 0f C L�LwN f7r� CARE OF D SS INFO MATION <br /> V yJ1() lU. 1 d/ /KQA f r STREET ADDRESSCC�� ✓Box to intlicate ❑yAjjTNERSHIP ST✓ r n1 ❑ CORPORATION $LOCENCY <br /> AL-AGENCY ❑ FEDERAATE GAGENCV <br /> - ❑ INDIVIDUAL ❑ COUNT+0/ I�_,{T STA ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> ad <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 0 II. 111 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> El <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION M - <br /> m � _ AGENCY N FACILITY ID M <br /> ^ t of TANKS at SITE <br /> CURRENTLOCAL AGENCY FACILITY ID R <br /> ,A P C) AP E— PHONE M WITH AREA CODE <br /> 'v / <br /> PERMIT NUMBER------_ _PERMIT-APPROVAL DATE _. __ - <br /> -- - PERMIT EXPIRATION GATE <br /> LOCATION CODE CENSUS TR,%� SUPERVI30 -0 vo lv� LYTRICT CODE BUSINESS PLAN FILED <br /> GATE FILED <br /> YES NO LL <br /> CHECK is PERMIT AMOUNT SURCHARGE AMOUNT <br /> FEE CODE RECEIPTX <br /> 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 INFORMATION ONLY. <br /> RMA(3-2-B8) <br /> — • DATA PROCESSING COPY • <br />