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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD R ss <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> v COMPLETE THIS FORM FOR EACH FACILITY/SITE `^��i ." Ccs• <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ j,PERM EN C SED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE QI <br /> GTI <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 4w <br /> Cfl <br /> FACILITY/SITE NAME <br /> �Do+_ <br /> u <br /> CARE OF ADDRESS INFORMATIONs� <br /> ADDRESS =STREET ,tPWw!e ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> IllVlowl ❑ COUMY AGENCY <br /> CITY NAME SITE PHONE a,WITH AREA CODE <br /> T2 Za - 83 - S <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR I ✓66d INDIAN EPA ID a <br /> RESERVATION or #01 T IS I <br /> ❑ 1 GASSTATION E]3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,REST) PHONE#WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE a WITH AREA CODE <br /> ' e Zo9— X3/-SDs7 SnI.1,I...R-- �Zo9-8sY-Sbs7 <br /> NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> c�5 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SwvA,.e- <br /> MAILING or STREET ADDRESS ✓Box tointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE 71P CODE PHONE a,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. 40II. ❑ 111.❑ <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 Is AGENCY# FACILITY IDR #01 TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID Of APPROVED BY NAME PHONE Al WITH AREA CODE <br /> ,+6 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRRA(CTT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D 2-' DO 3Z YES NO _ 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT A! Y. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI CSS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM.A(3-2-88) <br /> "� DATA PROCESSING COPY '�'�' <br />