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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD E-oF <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM = ' o <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-] 1 NEWPERMIT F-13 RENEWALPERMIT CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE F-a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE —4 <br /> IV <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (ZD <br /> FACT TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G e C0 <br /> ADDRESSsi NEAREST CROSS STREET mdih e Cl PARTNERSHIP 0 STATEAGDO <br /> COIPOMTION 0 LOCKAGBXY 0 FEDEREAEFNCI <br /> ❑ IKMD)AL 0 COUNTY AGENCY <br /> [!NAtE ^ STATE ZIP CODEQ SIT PHONE N.WITH AREA=;4 P. <br /> r."leilm, CA <br /> TYPEOFBUSINESS: 02DISTRI&TOR ❑4 PROCESSOR ✓Bo%AINDIAN EPA ID N <br /> RESERVATION or N of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> QD G S�-Y <br /> NIGHTS: NAM (LAST.;FIST) HONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a r i na. e <br /> MAILING or STREET ADDRES ✓ x to intlicele 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA� 0 T S G M I STATE ZIP E PHONE q.WITH AREA CODE <br /> ✓r <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r <br /> O <br /> MAILG or STREET <br /> INADDRESS V/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 11CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREBS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 9 <br /> 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY N FACILITY ID tl N of TANKS at SITE <br /> ® = = I odaa o00 <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ] <br /> LOCATION CODE CENSUS TRACT� _ ❑ <br /> SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED <br /> 3OjCJ/\ li <br /> YES NO 1 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If B <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 /> FORM A(3-2-88) J <br /> \\V\T' DATA PROCESSING COPY <br />