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oT <br /> STATE OF CALIFORNIA— WATER RESOURCES CONTROL-iOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : l o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER LY CLOSED SITE F-L <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE,�;^ME CARE OF ADDRESS INFORMATION <br /> l� - OG7 /0 <br /> ADDRESS NEAREST CROSSSTREET ✓NP mir6cme D PAUNDGIIP STAT AGM <br /> u u J / 0 PWAAiIGN O W1JIUr AGENC CALAGRO F1 OEWAGN <br /> INNDM <br /> CITY NAME `� / STATE ZIP CO E / SITE PHONE 11,WITH AREA CODE <br /> TYPE OF BUSINEBS: ❑ 2 DISTRIBUTOR ❑4 P ESSOR -/Box if INDIAN EPA ID a 1/ S X of TANK's //�� <br /> RESERVATION or El AT THIS SITE (J <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHEfl TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Al. este -9 �, p srti...� <br /> NIGHTS: NAME(LAST IRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> U k 1-0 9­14-7`V6 6 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ­19-6-IN ! CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDR S S -/Box to indict. 13 PARTNERSHIP TATE-AGENCY <br /> 0f R D CORPORATION 1:1 LOCAL-AGENCY FEDERAL-AGENCY <br /> It <br /> v Vc ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME SZy STATE— ZIP CODE PHONE k, TH AREACQDE (�D <br /> III. TANK OWNER INFORMATIO�F//NLL99&ADDRESS – (MUST BE COMPLETED) <br /> JMPPLETED) (Qy/6(�7 <br /> NAME S <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to intlicate D PARTNERSHIP D STATE AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: I. ❑ it. [kr III.❑ <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 M AGENCY N FACILITY ID k M of TANKS at SITE <br /> = = 0 y G <br /> CURRENT LOCAL AGENCY FACILITY IDM CA L:rg I t APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONCODE CENSUSTRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YQ yYES PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> /2-8–Pff <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¢RN�A(3-2-BB) <br /> FO ` DATA PROCESSING COPY ""Y <br />