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{ .STATE OF CALIFO yti4O% <br /> WATER RESOURCES CC"� ROL BOARD <br /> 9t'� - <br /> FORM `A'. <br /> • J <br /> UNDERGROUND STORAGE TANK" OGRAM ' " '1 <br /> SST FACILITY/SITE, INFORMATION and/or PERIkMRIT APPLICATION r� <br /> o� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> .h <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION1:12 INT7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ ERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME :I <br /> r ^C�O a CARE OF ADDRESS INFORMATION . <br /> q A40t1J <br /> ADDRESS NEAREST CROSS 5'REET �/ p ❑ � <br /> JnQ Q r } ih ❑ TAKRAnam (!'f_=k-,�M Q �r Biu- is I <br /> r rs nl'I Cl "IBM)tlAL ❑ =NTT-AGa:rIcY I <br /> CITY NAME _. CODE SITE PHONE K"WITFE AREA CODE <br /> AlU\ ca �� U Cao �t 5�-Y3�1 <br /> TYPE OF BVSiNE5S: ❑ 2 DismaUTOfl ❑ 4 ROCESSOft ✓Bax if INDIAN EPA ID # 11 <br /> 1 GAS STATION [:13 FARM 5 OTHER RE5ERVATIO!or ❑ Alen <br /> � AT THIS SITE <br /> ❑ TRUST LANDS l � <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST.FIRS—n PHONE 4 WITH AREA CODE <br /> GeS a CdOq 0 ,' if <br /> NIGHTS: NAME(LAST.A ST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Intlicare ❑,�,�RTNERSHIP ❑ $TATE-AGENCY <br /> ` C] CORPORATION I L LOCAL•AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INOIvIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZI COOE PHONE�,W1TH AREA CODE <br /> c- <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) .t'l <br /> NAME rr !! CARE OF ADDRESS INFORMATION r <br /> $frk <br /> MAILING or STREET ADDRESS ✓6ox to i6cate Cl PARTNERSHIP Cl STATE•AGENCY <br /> \'1 ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> J Cl INDIvtOUAL i� ❑ COUNTY-,AGENCY <br /> CITY NAME STATE T ZIP GOOE PHONE Fr.'6VH AREA CODE <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. 1. 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TNF BEST IOF MY KNOWLEDGE.IS TRUE ANO CORRECT. <br /> APPLICANTS NAME(PRINTED BSIGNATURE) �' DATE <br /> :j <br /> LOCAL AGENCY USE ONLY l N <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Ll E:I--- 1 1 .h <br /> 10 lD 1. '` a � D0 <br /> CURRENT LOCAL AGENCY FACILITY ID N i APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION 70DE CENSUS TRACT N SUPERVISOR-OISTRtCT CODE susimESS PLAIT FILED DATE FILED <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE "I RECEIPT* BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),k UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. # <br /> FORM A(3-2-88) <br /> DATA v ' PRocEsslNc coPYl i � <br />