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6 t. P� •u .* I " * <br />4e. FA <br />STATE OF CALIFORNA WATER RESOURCES CONTROROARD <br />FORM'A': <br />UNDERGROUND STORAGE TANK PROGRAMw fto <br />SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE i Fo Rt 0, <br />ARK ONLY F❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 2_15 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />M <br />0O <br />NE I 2 INTERIM PERMIT D 4 AMENDED <br />6 TEMPORARY SITE CLOSURE <br />1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br />L(Lloll� <br />ADDRESS NEAREST CROSS STREET -/ BW to indeW Q PARTNOWIP Q STATE -AGENCY <br />RTRAlION Q LOCAL AGENCY 0 FEDEW AGENCY <br />I IDUAL <br />0 COUNTY -AGENCY <br />CITY NAME STATE ZIP COPE SITE PHONE #. WITH AREA CODE <br />15� kf CA <br />TYPE 0 USINESS: 2 DISTRIBUTOR <br />F-] 4 PROCESSOR <br />✓ Box it INDIAN <br />EPA ID # <br /># of TANK's Il <br />S STATION 3 FARM <br />.71 GA! <br />_] 5 OTHER <br />RESERVATION or <br />TRUST ❑ <br />AT THIS SITE <br />�f <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />INDIVIDUAL 0 COUNTY -AGENCY <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />RE,L4-0 c/Loa-0- <br />2-000 <br />erffg'406 <br />I <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />I NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NAME CARE OF ADDRESS INFORMATION <br />,- (4 <br />MAILING or STREET ADDRESS V Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />6 <br />RPO <br />RATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY It 2__ 'v_ &INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME STATE ZIP CODE f PHONE If, WITH AREA CODE <br />NA <br />CARE OF APDRESS FORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />0ORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE fl, WITH AREA CODE <br />/C—) � e� /'_'/ <br />CHECK ONE (1) BOX INDICATING WNIC H ABOVE ADIDIRIESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. El 11. 0 m. El <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) <br />DATE <br />lt*Tof-,l• <br />NAME PHONE # WrrH AREA CODE <br />PERMIT NUMBER PERMIT EXPIRATION DATE <br />LOCATION CODE SUPERVIS7DISTRICT CODE BUSINESS PLAN FILED <br />13 2- YES NO <br />