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STATE OF CALIFORNIf WATER RESOURCESCONTROROARD z�o. <br /> xf <br /> FORM NA': <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEBMANtKLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r,fi, moro <br /> ADDRESS NEAREST CROSS STREET ✓SIN to tl D PARTNERSHIP 0 STATEAGENLY <br /> ❑ ONKRATION ❑ LOC4 AGENCY ❑ FEDERAL AGOAN <br /> ❑ INDNIDUAL ❑ CWNTY-AGENCY <br /> CITY NAME 1 STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box'INDIAN EPA ID N <br /> RESERVATION or «oI TANK'F <br /> ❑ 1 GABSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to intlicate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ 111. ❑ <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 /> COUNTY11 JURISDICTION M AGENCY k FACILITY ID N R of TANKS at SITE <br /> —u;L 1 0 1 0 1 ) I d o 15 10, <br /> CURRENT LOCAL AGENCY F ILI I T 10IF 16 1 1 APPROVED BY NAME PHONE N WITH AREA CODE <br /> A M F-I <br /> (y/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> `� [CHECK <br /> LN <br /> E CENSUS TRA SUPERVIDISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> `(vim YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ON% <br /> FORM A(3-2-88) _ F� <br /> cli <br />