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STATE OF CALIFOINO WATER RESOURCES CONTR•OARD <br /> FORM 'A': ; <br /> UNDERGROUND STORAGE TANK PROGRAM w m <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ? wo <br /> C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE s.�„opr,P t Cf <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ElLOSED SITE <br /> I. FACILITY/SITE INFORMATIOny <br /> ❑6 TEMPORARY SITE CLOSURE <br /> FACILITY/SITE NAME O, <br /> N & ADDRESS — (MUST BE COMPLETED) cror <br /> J <br /> ADDRESS SAa <br /> CARE OF ADDRESS INFORMATION <br /> 15 <br /> 5 I NEAREST CROSS STREET ✓Bw 10 imrale ❑ PAIRNERSHIP ❑ STATE <br /> / AGEN <br /> CITY NAME �( 7 ❑ INDIVIDUAL ❑ CO,N1Y gGENLY LOCAL AGENCY ❑ FEDERAL AGENCY <br /> STATE ZIP CODE '7 SITE PHONE 9,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR `/Bax it INDIAN EPA ID pA S/33 Za y— Z <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER RESERVATION orNof TANK's M <br /> TRUST LANDS EDAT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITHAREAODE DAYS: NAME(LAST,FIRST) <br /> K vZloil t& 10`..Iq ' ``II PHONE B WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) V/7 PHO EAl WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE N WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CAHE OF ADDRESS INFORMATION ) <br /> MAILING or STREET ADDRESS '/80.to intlicale ❑ PAg7NERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> Cl INDIVIDUAL ❑ FEDERAL-AGENCY <br /> CIN NAME ❑ COUNTY-AGENCY <br /> STATE IZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> CI Y NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE p,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: 1. ❑ 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 /> COUNTYLI JURISDICTION N AGENCY N FACILITY ID N <br /> _ Nof TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME <br /> ,T y� PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPtgATION DATE <br /> LOCATION ODE CENSUS TRAP N M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED <br /> CHECKNPERMITA AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPTa <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE <br /> FORM A(3-2.88) TANK PERMIT FORM 'B'APPLICATION(S), UNLES IS IS A CHANGE OF SITE INFORMATIO%NONLY. <br /> •�!I� DATA PROCESSING COPY <br />