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STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD e <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" "a sr <br /> P <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C9<iFOPN�P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE w <br /> MARK ONLY ❑ 50 W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 01 <br /> FACILITY/BITE NAME CARE OF AFORMATION <br /> DD ESS IN <br /> IY QvoYLSLu-ci--Dn c_ t,:) <br /> ADDRESS � NEAREST CROSS STREET ��✓§oxm BWkak 0 PART IP ❑ SATE AGENCY <br /> 2- 11 <br /> l l 1i — 0 FAflPORATION 0 LOCAL ❑ FEDEPAL AGENCY <br /> 0 INDIVIDUAL 0 LOAL AAGENCl <br /> CIN NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA gSa05 l < <br /> TYPE OF BUSINESS'. ❑ @ DISTRIBUTOR ❑4 PROCESSOR ✓Bax it INDIAN EPA IDN #of TANK's <br /> RESERVATION or ❑ _�—' ATTHIS <br /> SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> PHONE ft WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) —� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS v` ✓Co.to ia0icale Cl PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION D LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS v ✓Bax w ia0icale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �— O 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> �bq -AImo--l\ '�p,�' I�NDIVIOUAL 000UNTY <br /> GENCY \ <br /> STATE ZIP CODE PHONE k,WITH AREA CODE <br /> CITY NAME <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 /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL^AGEN/ClY FACILITY IDM <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> r,v c)n PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> LOCATION CODE CEN C SUPERVISOR-DISTRICT CODE BUSINESS S N FILED NO ❑ FILED <br /> CHECKM <br /> PERMIT AMOUNT SURCHARGE AMOU T FEE CODE RECEIPTN BYE O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(B-2-BB) • <br /> DATA PROCESSING COPY <br />