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• OF f... <br /> STATE OF CALIFORNIA* WATER RESOURCES CONTROL BOARD 5."ivaiK;•NF <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM W to <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - ,> �* �o <br /> CCOMPLETE THIS FORM FOR EA CILITY/SITE C,OFO RNxP <br /> MARK ONLY ❑ I W PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PERUANENTLY SITE I'a <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a <br /> CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) tV <br /> FACILITY/SITE NAM f a CARE OF ADDRESS INFORMATION <br /> 0 IA�& V <br /> ADDRESS NEAREST CROSS STREET ✓Bax indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> '�// •�/J G/ //�� �j/I O RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (.►V / G L� IJO/L/7I, NDIVI <br /> /� � DUAL Cl COUNTY-AGENCY <br /> CITY NAME / � / STATE ZIP CO[)E / SITE PHONE#, ITH AREA CODE <br /> .`J IyA CA 9 s 2fi C7 <br /> TYPE OF sus SS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # �0 <br /> RESERVATION or #of TA a <br /> AS STATION 3 FARM ❑ 5 OTHER TRUSTLANDS ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) �� � PHONE#WITH AREA CODE DAYS: N��(LAST,FIRST)�/O` � ���E�IT�R�CODE <br /> P�4 At 13 <br /> NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE NIGHTS: NAME(LAS /FIRST) f/J_ PHONE#WITH AREA CODE <br /> Sam <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME F l<I , ) CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSVINDIVIDUAL <br /> to indicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> PORAT,ON ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> �t O ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 11,WITH AREA CODE <br /> 0 <br /> III. TANK OWNER INFORMATION &A DRESS— (MUST BE COMPLETED) <br /> NAME .� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B./l.indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> INDRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE <br /> ##,,WITH AREA COPES <br /> ��r / �/ f <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. ❑ 11. IVIII.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURF1 DATE <br /> LOCAL AGENCY USE ONLY <br /> FPERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> EI I] LO � 0 � 3 Dov <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> O <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILED01 �—;10 � YES NO �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: - x <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 /> FO A(3-2-88) <br /> r 0 DATA PROCESSING COPY <br />