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l <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH F ITY/SITE 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE !/ T <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) of <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N <br /> ADDRESS E-, <br /> ` ]NEAREST CROSS STREET ✓AmroiFe 0 PAXTNEIMIR ❑ STATE.AGENCY, <br /> 33 3 Cn ?/i ❑ Go 00RATUN 0 LOLLAGDO ❑ FEDEXAGENCYINCVIDUAI 0 COUNTY AGENCY <br /> CIN NAME _ TATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> ( CA S33 <br /> TYPE OF BUSINESS: M 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID k <br /> RESERVATION #of TANKs <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS Or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,RRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> />oc"ear4. : N —5-1"9 a cx/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bon to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 7 sJ� GJ� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODEPH ONE N,WITH AREA CODE <br /> i v C,¢ s33 C7�9 <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S4Ak-e cs <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ___ ❑ INDIVIDUAL 0.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. ❑ IL III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = = 10101 / 12KE] U oa <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ivu�-A L 33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OATS FILED <br /> d� 2 3 ,2(1 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS"I OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. Q <br /> FORM A(3-2-a8) <br /> DATA PROCESSING COPY `I <br />