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R <br />77 <br />OF <br />.STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PR <br />r.� <br />SITE- FACILITY/SITE, INFORMATION and/or PERMI DECI O -,4, <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE C 6 1989 "``FOR"_" y <br />' ' ° CLOSED SITE <br />MARK ONLY �] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OFPiMATIQN t •.,I V Lt r <br />ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE 4 V' F,�I i (/ 4E.RVICES <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NAME CARE�OF��DDRESS INFORMATION <br />, NEARESTCROSS TREET ✓Bn�taindicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />ADDRESS <br />l ,/�1 WRIT NATION ❑ COUNT -AGEN ❑ FEDERAL AGENCY <br />0 _ pNIpuAL ❑ CGUNIY-AGENCi' � <br />CITY NAME STATE ZIP C DE SITE PHONNE # WIT AREA CgDE <br />TYPE OF BUSINESS: F-1 2 DISTRIBUTOR 4 PROCESSOR ✓ Box if INDIAN EPA ID 4 R of TANK's <br />RESERVATION or AT, THIS SITE <br />1 GAS STATION . Ej <br />❑ 3 FARM E] 5 OTHER TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME LAST, FIRST) PHONE k WITH AREA CODE DAYS NAME (LAST, FIRST , / 1 PHQNE #WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE N WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME Y CARE OF ADDRESS INFOR MATION <br />LS .� <br />MAILING or STREET DDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />h `� / ❑ �ff;DRPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME 3 ST ZIP CODE PHONE 4, WITH AREA CODE <br />111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAMEL <br />CARE OF ADDRESS INFORMATION <br />✓ Box to indicate ❑ PARTNERSHW ❑ STATE -AGENCY <br />MAILING or STREET ADDRESS <br />`7 _ ')RP' <br />❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />LJ INDIVIDUAL ❑ COUNTY -AGENCY <br />STATE ZIP CODE PHONE 4, WITH AREA CODE <br />j <br />CIT�AME' <br />I <br />IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br />CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR GOTH LEGAL NOTIFICATION AND BILLING: I. II. 111. <br />THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />APPLICANT' NAME (RRINTED 8 ATURE) / DATE <br />6 k <br />