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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> .. a <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> o� l o ' <br /> Cl COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 71EERMAINTLY tOSEEFSITE 1-& <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURES' <br /> cn i <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CE <br /> FACILITY/SITE NAME /,,/ LCARE OF ADDRESS, F RMATION <br /> COINS f/ !c Wor ,. <br /> l «Jy7dI✓ <br /> ADDRESS ®� NEAREST ROSS STREET ✓Dw 0, le ❑ PAARIEPSIIP ❑ STATEAGEN:Y <br /> 23o N. CkL(rc4, - rce� Qt� iNDN,DouI� O coocnry AGE Ct ❑ F nnLACEN <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> L/� CA S 2 O <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID # V <br /> RESERVATION arM of TANK'S <br /> ❑ I GAS STATION ❑ 3 FARM L?r5 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#WITH AREA CODE <br /> IGHTS: NAM�ST,FIRS ) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> u,kN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEAMA s 1 CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Boz to intlicalo ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AS = <br /> MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ 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 WNICH ASOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ III.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CmmNTY# JURISDICTION# AGENCY# FACILITY ID# #o/TANKS at SITE <br /> L�-L J 6 © 3 '7 d U D U <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT IfERVISOR-DISTRICT CODE BUSINESS PLAN FILED `DATE FILED <br /> a s.3 SUP /! YES E] NO F] <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> • \ FORM A(3-2-BB) J( <br /> \N DATA PROCESSING COPY <br /> VVV I <br />