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STATE OF CALIFORIO WATER RESOURCES CONTO BOARD <br /> FORM A: ul <br /> UNDERGROUND STORAGE TANK PROGRAM Go <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ®< <br /> G. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY7SITEN4CARE OF ADDRESS INFORMATION <br /> 4VTD AF <br /> ADDRESS _ NEAREST CROSS STREET 116mbii6ob ❑ PARDE 41P 0 STATE-AGDy <br /> ❑ DWMTaN 0 LOXAGDILY 0 FEDENI./GENLY <br /> ❑ INDMOM 0 1X11 m-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PrON N,WITH A"R�COD <br /> b� CA Zo b —4 y D <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑/P ESSOR I/Box 2INDIAN EPA ID N <br /> ❑ I GAS STA710N 3 FAPo.1 5 OTHER RESERVATION or o17ANK'N <br /> ❑ TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE/I WITH ARS�CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> oP6Z �ZDe 6 —9�fr7 <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 /> MAILINGo,STREET ADDRESS ✓Box to indicate PARTNERSHIP 0 STATE-AGENCY <br /> /� / ( ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 220 �' /-I�F�Iy 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> Ck D <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> E w.9,Q <br /> MAILING o,STREET ADDRESS %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> / � 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 27.2,->- - �YikAl 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> S� <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. [7, 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 N JURISDICTION R AGENCYI! FACILITY ID N N of TANKS at SITE <br /> OD 1 ( ( 7 0 1 o 10a <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> D Zz <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION N CODE CTRACT SUPERVISOR-DISTRICT CODE BUSINESS <br /> HECKATIOENBN,^ zz- 2SE N❑FILEO NG ❑ DATE / <br /> CHECK PERMIT AMOUNT S CHARGEAMOUNT FEECODE RECEIPT BY: <br /> I _ <br /> f <br /> 0—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 /> FORM A(3-2-88) 0< <br />