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STATE OF CALIFORNI WATER RESOURCESCONTROLBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m : 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE I'll ^W" <br /> MARK ONLY ❑ DREW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'A' <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 w <br /> CD <br /> 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) A <br /> n F-� <br /> FACILITY/SITE NAME j// // • CARE OFADDRESS INFORMATION <br /> ADDRESS NEAREST CROSSSTR�EE.7 AMP El 57ATE-AGRO <br /> AAiION ❑ LOCAL- ❑ C//, A4/" _ � WN <br /> ❑ ODUNIY.AGENC/ <br /> CITY NAME S71STATCA ZIP CODE / SITE PHONE�ITHA EA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 OCESSOR ✓Box ii INDIAN EPA ID# #a1 TANK'a6 Cl <br /> ❑ I GASSTATION 3FARM 5OTHER RESERVATION or - /( AT THIS SITE <br /> ❑ � TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) rr PHONE#WITH AREA CODE <br /> "ASO, IFA4 "Ut463-7:24? <br /> NIGHTSAMEST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (LA <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME -, A , M CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I M-f/V oxto intlicate 11 PARTNERSHIP 11E) <br /> 0 1 YD �C �I CORPORATION ❑ LOCAL-AGENCY E) FEDERAL-AGENCY <br /> IJ D / INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE_ _ ZIP CODE VS' PH ,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /} * � CARE OF ADDRESS INFORMATION <br /> WYNi <br /> MAILING or STREET ADDRESS xto intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION C LOCAL-AGENCY ❑ 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. ❑ it. ❑ 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# /1 V#)of TANKS at SITE <br /> 0 1 2 (oV <br /> O O2- <br /> CURRENT LOCAL AGENCFACILITY ID# APPROVED BY WRIE PHONE#WITH AREA CODE <br /> Af 2 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTS#T# SUPERVISOR-DICT CODE BUSINES,PLAN F❑ILED NO ❑ DATE FILED <br /> Q <br /> CHECK M 1 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 INFORMATION ONLY <br /> 1 FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />