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0s <br /> STATE OF CALIFORNI WATER RESOURCES CONTR OARD � <br /> :� ro. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ® o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �9lIFOPN.P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANFNTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ED 6 TEMPORARY SITE CLOSURE r 5 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> L. r N uesfi <br /> NEAREST CRO SS STREE,T1� ❑✓,Barb idrsV ❑ PARTNERSHIP El STATE AGENCY <br /> ADDRESS `` S I L7j INDIVIDUAL� � ❑ CAttAG C[3 LOCAL AGENCY ❑ fEOEMLAGDILY <br /> ED <br /> SITE PHONE N,WITH AREA CODE <br /> STATE ZIP CODE <br /> CIN NAME CA r <br /> S4 O� I/Box if INDIAN EPA IDN N of TANKY <br /> TYPE OF BUSINESS: 2 DISTRISUTOfl <PROCESSOR RESERVATION or � AT THIS SITE <br /> I GASSTATION 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAVS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> W SII _q�// _zI5 Z7 PHONE N WITH AREA CODE <br /> MGHTS NA E(IS ST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ^r 0 j <br /> MAILING or STREET ADDRESS ✓Box to irmicate Cl PARTNERSHIP <br /> FEDERAL-AGENCY <br /> PARTNERSHIP ❑ STATE AGENCY <br /> 0 LOCAL-AGENCY <br /> ❑ NORPORAION ❑ COUNTY AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> r <br /> e S ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOGAL-AGENCY D FEDERAL-AGENCY <br /> [I INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.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. v II. ❑ 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 N AGENCY N FACILITY IDN N of TANKqCODE <br /> f:j <br /> CURRENT L AGENCY FACILITY ID N <br /> APPROVED BY NAME PHONE N WITH A <br /> q2 q6 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> IFC� ZS- YES ❑ NO F] Z r� <br /> CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY. n <br /> ,JHIS FORM MUST BE ACCOMPANIED BY AT LEAST fOR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / <br /> /ALO/F/GSM A(3-2-88) <br /> l�—// t U <br />