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Of�. <br /> STATE OF CALIFORNIA` WATER RESOURCES CONTROL BOARD s <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM z <br /> 8.: 10 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION off,. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARK ONLY F-1 I NEW PERMIT ❑3 RENEWAL PER ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE -4 <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) <br /> 0 <br /> 1.FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> CARE Of ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> r <br /> �!gp, ClPAR1NE0.5HP ❑ SiAiE.AGENC <br /> ADDRESS // NEAREST CROSS STREET ❑ MTLN ❑ Look.KOO ❑ FEOERLLAGENC• <br /> L-i �la�rC6l!/�/ A - INGMWAL ❑ <br /> STATE ZIP CODE SITE PHONENE#,N.WITH <br /> AREA CODE <br /> CITY NAME r CA ry s 1.ns /11 <br /> �T'vc lG n L v'N/ <br /> TYPE OF BUSINESS'. ❑ 2 IBUFOR ❑ 4PROCESSOR -/Box if INDIAN EPA ID N aof TANICF <br /> 5 OTHER RESERVATION or r-7 <br /> AT THIS SITE <br /> ❑ 1 GAS 5IATI ON FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓'lox <br /> to In ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L3 cc <br /> VIDRATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C?9J��rG !�(�'� (/1 DIUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to -"ate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ 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. 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 N JURISDICTION B AGENCY R FACILITY ID N M of TANKS at SITE <br /> Eil I I I q I l v 10 1 i <br /> CURRENT LOCAL ZEr FAyIL�1 0 /]� APPROVED BY NAME PHONE N WITH AREA CODE <br /> II PERMIT NUMBER (I�/f'11�1 !/P'EIRMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-D STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> LNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: C <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) '+ <br /> �.- DATA PROCESSING COPY *ad- <br />