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i 'A <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =� "�� Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> to <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑�PERMANE§CLOSEDTEMARK ONLY ❑ t NEW PERMIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PER ❑6 TEMPORARY SITE CLOSURE � <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FAC /SITE NAME <br /> GNEAREST CROSS STREET ✓Bwarogate, Cl FARINEMIP ❑ STATEAGENLY <br /> ADDRESS [3CoWoAATI0N ❑ LOCAL-AGENLY ❑ FEOERALAGENCY <br /> _ ❑ IONIONAL ElC(M1NTf'AGENd <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CITY NAME, <br /> N CA 211S- <br /> Box if INDIAN EPA ID N p of TANK'N <br /> TYPE OF BUSINESS'. ❑ p RIBUIDH ❑ 4 PROCESSOR RESERVATION or ❑ AT THIS SITE <br /> F <br /> BASSTATION 3 FARM ❑ 5OTHER TRUST LANDSGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> . NAME(IASL FIRST) PHONE N WITH AREA LADE NIGHTS'. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> nNAME / ✓Box to indicate ❑ PARTNERSHIP ❑ FEDERAL-AGEY <br /> 0 LOCAL-AGENCY <br /> ❑ NDRV DUALION ❑ COUNTYAGENCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N,WI <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME SS <br /> D LOCAL-AGENCY <br /> MAILING or STREET A�RESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ NDRVIORALON ❑ COUNTY-AGENCY <br /> ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE it WITH AREA CODE <br /> CITY NAME <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. I-f[J 16 F-1 Irl. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DnTE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION If AGENCY p FACILITY ID p p of TANKS at SITE <br /> 006 <br /> CURRENT LOCAL E Y FACILITY I N APPROVED BY NAME PHONE N WITH AREA CODE <br /> m64� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUST ACTN SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO ❑ DABTEf�D <br /> 23.23 Z� <br /> CH K N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />