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O <br /> STATE OF CALIFORNIA WATER RESOURCES CONTRBOARD any <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> z a <br /> F : ,O <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT <br /> ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C.A) <br /> N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) cy) <br /> yi <br /> ORMATION <br /> FACILITY/SITE NAME n <br /> EET 1 ✓ X 0 PARTNERSHIP ❑ FECERSTATE AGENCY <br /> ADDRESS OSS, C� !VI/1 rE COAPORALION ❑ COUNTY <br /> OUNTYAGNCAL ❑ FEDERAL AGENCY <br /> 8O rn `�dCr1 ❑ INpIVIOIIAL ❑ OOURI WITHCiIP ODE�� SITEPHOONE N,W TH AiiEA CODE S_GIN NAME S n'(. 40 *Uy dl-�m✓Box it INDIAN #of TANK's <br /> TYPE OF euslNEss'. 2 DISTRIBUTOR ❑ 4 PROCESSOR RESERVATION or ❑ �- AT THIB SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) HONE X WITH AREA C E DAYS NAME(LAST,FIRST) <br /> PHONE X WITH AREA CODE <br /> NIG 5'. NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) <br /> PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME ' I l _ <br /> LI�AJ <br /> �\ K�R <br /> x to"dicate Cl RATION ❑ ENCY <br /> PATNERSHIP ❑ FEDERALCl STATE GAGENCY <br /> MAILING o TRE ADD SS UAL ❑ COUNTY-AGENCYZIP COrDEEPHONE X,WITH AREA CODECITY NAME y/ 214III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME ✓�� C...f� �fi�' <br /> (` ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,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. II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANT'S N E(PRINTF 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R a- 2 <br /> R AGENCY N /\FACILITY IDX X of TANKS at SITE <br /> ® 1 <br /> CURRENT LOCAL AGEy _e-IAPPROVED BY NAME PHONE X WITH AREA CODEPERMIT NUMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE SUPERVISOR-DIST�CODE BUSINESS PLAN FILED DATE ILED <br /> YES E] NOCHECK SURCHARGE AMOUNT FEE CODE <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTOR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNL�THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) S <br /> DATA PROCESSING COPY <br />