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STATE OF CALIFORNIA WATER RESOURCES CONTROSIOARD <br /> r. <br /> FORM `A': '. <br /> UNDERGROUND STORAGE TANK PROGRAM P, <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> El <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE w <br /> F� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> O <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> ADDRESS _ NEAREST CROSS STREET ✓BowlRrra16 Cl PARINEASHIP ❑ STATE AGENCY <br /> GORPOMTION ❑ LOCAL AGENCY ❑ FEDEM.AGENCY <br /> ❑ INDIVIDUAL ❑ COUN7rAGENCY <br /> CIN NAME STATE ZIP CODE SIT PHONE 4,WITH AREA CODE <br /> �iTC�19 CA533 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION or R of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM HER TRUST LANDS ❑ 19� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 9 X 135/0/ <br /> NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> N P <br /> MAILING or STREET ADDRESS ✓P4,0 <br /> locicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> M <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME KluffP19 r0410 <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or S7 ADDRESS ✓Boxl - e 11 PARTNERSHIP ❑ STATE-AGENCY <br /> A PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> U ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PH NE#,WITH AREA CODE <br /> 1­7 s336 -356 <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. ❑ It. <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 M JURISDICTION a AGENCY N FACILITY ID N M o1 TANKS at SITE <br /> 10 16 1 f b U <br /> CURRENT LOCAL AGENCY <br /> FACILITY ID N APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER N PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION DE CENSUS TRACT k SUPERVISOR- (STRICT CODE BUSINESS PLAN FILED DATE FILE <br /> O �� �/ YES NO ❑ � � <br /> CHECK K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 ONLY. <br /> RM A(3-2-88) Q <br /> 0 DATA PROCESSING COPY 0 1 <br />