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STATE OF CALIF ,5- �K,•T�, <br /> ORNI WATER RESOURCES CONTROL BOARD ems: <br /> IWP. �S•A <br /> FORM `A': .� �. <br /> UNDERGROUND STORAGE TANK PROGRAM � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °q�Fp..-p-N%P <br /> h <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑.2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACT /SITE NAM ^J �l� CARE FAD R S INFORMATI <br /> 1 �r(a A,1 <br /> ADDRESS v NEAREST CROSS STREET ✓�ofctoindicate ElPARTNERSHIP ElSTATE-AGENCYCD <br /> B CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1:1INDIVIDUAL El COUNTY-AGENCY <br /> CITY NAME STATE ZIP C SITE PHONE#,WITH AREA CODE <br /> CA 0 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID <br /> RESERVATION or #of TANK's <br /> -6AS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ /,q AT THIS SITE 04— <br /> EMERGENCY <br /> 4— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAfuIE(LA T,FIR T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> FIR T PHONE#WITH AREA CODE NIGHTS: ME(LAST,FIRST) PHQ6W5#WITH AREA CODE <br /> II. PROPERTY OWNER NFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF AD ^^RESS INFORMATION <br /> �A <br /> MAILING or STREET ADDRESS Vjiol6to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ff CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> b ��J ((( ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE _ PHON WITH REA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME �/J CARE OF ADDRESS INFORMATION <br /> r l• 1f-O <br /> MAILING or STREET ADDRE�4 ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 5111 <br /> a STATE ZIP CODE PHONE#,WITH 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. ❑ If. Ill. ❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> -1 E[® Z C Q <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Q k/.5 -7,-b <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE FIVD <br /> KJ� �3 YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT_f # BY: <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 ONL . <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />