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STATE OF CALIFORN19 WATER RESOURCES CONTROBOARD <br /> FORM 'A': s <br /> UNDERGROUND STORAGE TANK PROGRAM a' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °+<„o i4 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ INFORMATION 6 TEMPORARY SITE CLOSURE ❑ T P Y CLOSED SITE I--► <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> W <br /> rADDRESS <br /> TE NAME �/ O <br /> JO �11y CARE OF ADDRESS INFORMATION <br /> u use— Gov'Pr(,yl <br /> 7pNEAREST CROSS STREET ✓EAwmiMi ale ❑ PppiLAGEP ❑ STATEAGENCY <br /> G lAIli-0�\ ❑ CgflPoH.4ilON ❑ LAGENCY ❑ fEGEflAL AGDILY <br /> ❑ WDIVIGUAL COUNTY AGENCY <br /> J-r� / STATE ZIP C OE SITE PHONE k WITH AREA CODE <br /> INESS: W{— CA <br /> ❑2 DISTRIBUTOR 4 OCESSOR ✓Box if INDIAN EPA ID 4 <br /> ❑ I GAS STATION ❑3 FARM Elr5 OTHER RESERVATION or ❑ X of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /� -2-0 — �� ��� PHONE N WITH AREA CODE <br /> f <br /> NIGHTS: NAME(LAST,F ST) PHONE 4,AWITH_A p OO NIGHTS. NAME(LAST FIRST) —� <br /> v( 3p/ /, /- PHONE 4 WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> (V ` w ti CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS l/•ya• ✓Box to,ndoole ❑ PARTNERSHIP <br /> 0 STATE-AGENCY <br /> Z Z Z S ❑ CORPORATION LO L-AGENCY FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL OUNTY-AGENCY <br /> J STAT ZIP CODE PHONE 4,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET A�D'DJRESS /V(�/ JL ✓Box to indicate ❑ PARINERSHIP <br /> / �p? ! � ❑ CORPORATION [� LqL- ❑ STATE-AGENCY <br /> ❑ <br /> CORPORATION <br /> _ AGENCY ❑ FEDERAL-AGENCY <br /> CITU NAME COUNTY-gGENCY <br /> STAT ZIP CODE PHONE 4,WITH AREA COOS <br /> �o� Ta.✓ 9S2o� _ ;F 33 <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. ❑ II.—Elm-9--i <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 6 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1t JURISDICTION R AGENCY X® FACILITY ID N '7 k of/TANKS <br /> �at SITE <br /> CURRENT LOC L AGENCY F Y ID M APPROVED BY NAME <br /> Pl 1 I C PHONE M WITH AREA CODE <br /> PERMIT NUMBER �J V bb PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTZI� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> Z 3(jJ( DATE FILED <br /> 7iO YES ❑ NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPTA BY: <br /> � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE <br /> FORMA(3-2-SB) TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANCE OF SITE INFORMATION ONLY. <br /> 46 <br /> DATA PROCESSING COPY <br />