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STATE OF CALIFORNIA" WATER RESOURCES CONTROL BOARD <br /> „ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> iCOMPLETE THIS FORM FOR EACH FACILITY/SITE °'i�rox9�r <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN NTLY CLOSEDSITE I_& <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE - i <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) O4 <br /> cco <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> utc-- <br /> ADDRESS NEAREST CROSS STREET ✓Smmi ❑ PARTNERSHIP 1:1 STATE AGENLY <br /> II ; ! ❑ TION 11LOX-AGE10 11RDERALAGENCY <br /> u!�- NGmouu ❑ clwrDv.AGRlcr <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> cA Ic?saos IUtt-Z <br /> TYPE OF BUSINESS: p BIJTOR F-]4 PROCESSOR '/Box#INDIAN EPA ID# <br /> RESERVATION or ,I #of TANK'# f <br /> ❑ t GAS STATION 3 FARM S OTHER TRUST LANDS AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST.FIRSTI PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME //n9 ..y.- CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box dimte 13 PARTNERSHIP ClSTATE-AGENCY <br /> El El ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME C j CARE OF ADDRESS INFORMATION <br /> V( <br /> MAILING or STREET ADDRESS ✓Box l icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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 B JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 4 10 a 1 <br /> CURRENTLOf>wL AGGENOY FAC141 i l N APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER_ /`u�IVII Iyer PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3 a3 300-0-x- YES ❑ NO ❑ (0" <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 /> FORMA(3-2-88) <br /> �,. DATA PROCESSING COPY r rzo�0 Li[.,(d T <br />