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Sf'iuo� 'yF <br /> STATE OF CALIFORNIK WATER RESOURCES CONTRO BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ro <br /> to COMPLETE THIS FORM FOR EACH FACILITY/SITE �""�°"�� <br /> MARK ONLY ❑ ) NEW PERMIT F73 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERM OSED SITE F'a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE - <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> co <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓ Mo1e ❑ PNIREMP <br /> ADDRESS 11SN.IEAGEM,Y <br /> _ /.�� COPoN.To LOGLNSC! ❑ FEMRM.4680 <br /> �M !i ❑ IMDMDUN ❑ COUNIY WDIGY <br /> Vll (r STATE ZIP CODE SI PHONE <br /> CITU NAME N,WITH AREA CODE <br /> �fmwp CA 4 30 0 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ d P R ✓Boz 4INDIAN EPA ID If I N of TANK'# <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LRST,FIRST) PHONE#WITH AREA CODE <br /> 1d4 esr-s-/S7 <br /> NIGHTS: NAME(LAS .FIRST) PHONE If 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 /> 16gEy gf/S Po <br /> MAIUNG or STREET ADDRESS ' ✓ o RAT,le 0 PARTNERSHIP Cl STATE-AGENCY <br /> RPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#.WITH AREA COOE <br /> 7_ O/ D 6SS <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> f (�u/�tJS - o . <br /> MAILING or STREET ADDRESS ✓ to RATIe ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O B �„ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> p�� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME <br /> STATE ZIP ` PHONE I.WITHAREA CODE <br /> L <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.�/ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION K AGENCY K FACILITY ID If I #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILRY ID♦UU APPROVED BY NAME PHONE#WITH AREA CODE <br /> ,55 <br /> EITBER PERMR APPROVAL DATEPERMIT EXPIRATION DATEODE CENSUS TRACT# SUPERVISOR-0�CT CODE BUSINESS SN F❑iLEO NG ❑ DATEFlIED3 .3 7:PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> BY: <br /> \\r/I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE/" '1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> V FORM A(3-2-80) �. <br /> DATA PROCESSING COPY Y._ <br />