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I< ' <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> .i <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE `, FACILITY/SITE, INFORMATION and/or PERMIT�APPLICATION ,; 10 <br /> C� COMPLETE THIS FORM FOR EACH FACILITY/SITE `4�reorre'* <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P Y CLOSED 51 f E <br /> MARK ONLY ❑ ❑ ❑ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENOED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS !- (MUST BE COMPLETED) 0) { <br /> FACILITY/ TE NAME i3 CARE OF AOD SSINFORMATION j <br /> ADDR EAR/ did EE ✓Baabd ❑ PAFNR94 ❑ STATE-AGM <br /> ❑ WRMTION .I <br /> ❑ LOGLIVGE1lL1' <br /> ❑ m m k ❑ CMM-AGRCY /y <br /> CITY NAM STATE ZIP SITE PH N � COOE 1 <br /> 1- (�Jy <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID <br /> RESE❑ ❑ TRUST LANDS ATION or ❑ 1`' #of TANKHIS S O I <br /> 1 GA55TATION 3 FARM 5 OTHER AT THIS SITE 0 I <br /> EMERGENCY CONTACT PERSON(PRIMARY) ` EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAM (LAST,FIRST) PHONE N WITH AREA CODE <br /> A <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 1 <br /> r�L S7 .d -i <br /> . j <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAM r- CARE OF ADDf ESS INFORMATION <br /> MAILING or TREET A DRE F ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY EDE •AGENCY <br /> 311 Al- ❑ INDIVIDUAL, ❑ COUNTY-AGENCY � <br /> CITY NgiulE`, I. STATE ZIP CODE� ONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS,-- (MUST BE COMPLETED) <br /> NAME it CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE te,WITH AREA CODE } <br /> 'i <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. R. ❑ IEI.❑ <br /> THIS FORM WAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) '` DATE - <br /> �t 2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION AGENCY* FACILITY ID# N of TANKS a1 SITE ¢ <br /> a aLp—lo 10 01 1 <br /> CURRENT LOCAL AGENCY F ILYIY ID/ h APP"OVEDBY N ME PHONE N 1NITH AREA CODE52 <br /> k <br /> PERMIT NUMBER PERMIT APPROVAL DATE PER ITEXPIRATION D 1 <br /> LOG N ODE CENSUS TRA N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE <br /> Z3 f1 YES ❑ . NO A�IMAIL_ <br /> CHECK N PERMIT AMOUNT <br /> vv SURC14AFEGEIAIAOUNT FEE CODE RECEIPT N Y: <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 /> FORMA(3-2.88) —� <br /> DATA PROCESSING COPY <br />