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�/ moo.rr <br /> `STATE OF CALIFORNIA WATER RESOURCES CONTROL BDARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> `SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE µ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �( <br /> 1.FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) 01 <br /> lima FACILITY/SITE NAME �. _ .mss' r SRN CARE OF ADDRESS INFORMATION <br /> ADDRESS V NEAREST CROSSSTREET brook ❑ pmmuw ❑ STAR-mm <br /> IWC D �LAWO D FMOBLAGM <br /> r, NMSUAL ❑ caNnuEnc <br /> CRY NAME STATE ZIP CODE / SITEPJE WITH AREA CODE <br /> !2 G Sr V/ DULL// <br /> TYPE OF BUSINESS: 2 CR /PROCESSOR ✓Boz INDIAN EPA IDM i of TANK'M <br /> ❑ ❑ RESERVATION a ❑ AT THIS SITE <br /> E] 1 GAS STATION FARM ❑5 OTS TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> :77, DM ZAI <br /> NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> W. 11. PROPERTY OWNER INFORMATION&ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> s ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> MAILING or STREET ADDRESS 0 CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> r <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ✓Boz to RATIe D PARTNERSHIP D STATE-AGENCY <br /> MAILING w STREET ADDRESS <br /> [I CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> STATE ZIP CODE PHONE M,WITH APER CODE <br /> GTY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL F-1 ILL❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> RCHECK# <br /> Y N JURISDICTION N AGENCY M FACILITY ID N M of TANKS at SITE <br /> _ � ooh / � l 000 <br /> CALA I FACILITY IU NAPPROVED BY NAME PHONE R WITH AREA CODE(jJ�/,/�YI�I(ER PERYR APPROVAL DATE PERNIT EXPIRATION DATE <br /> ODE CEN��CTN SUPERVISOR-0ISTR CODE BUSINESS PLAN FILED DATE FILED1— ZZ YES [] NO ❑SUNGHAP E AM NT FEE CODE RECEWT M BY: <br /> PEIIYR AMOUNT &1/& <br /> WTHIS 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />