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� 1l <br /> STATE OF CALIFORNIA- WATER RESOURCES CONTROLOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7� ENTLV CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) r <br /> FACILITY/SITE NAME ! S/` (� RE OF ADDRESS INFORMATION <br /> ADDRESS I ! /r /1 NEAREST c'; _ ✓COWOUTce ❑ PARTNLook AGENCY <br /> FTATE EDERAL ENCY <br /> AGENCY/Y•/• IjEET�' ❑ GOlGO W.1i.,a+ ❑ taco-wRx+ Cl FFOFIULnc[Nc <br /> ❑ INDIVIDUAL Cl 000NIY,IGENCY <br /> CITY NAME /, STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: it INDIAN EPA ID # 7r <br /> ❑2 DISTRIBUTOR 4 P ESSOR Box if INDIAN _ Xof TANK's <br /> RESERVATION or ❑ AT THIS SITE <br /> 1 GAS SFATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH EA CODE DAYSNAME ST,FIRST) PHONE p WITH EA CODE <br /> 79 <br /> NIGHTS: NAME(LAST,FIRST) P'� PHONE a WITH AREA CODE NIGHTS'. NAME LAS1 T.FIRS PHONE a WITH AREA CODE <br /> �46II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME (�— �// j�y1� CARE OF ADDRESS INFORMATION <br /> C /1 XIV <br /> MAILING or STREET A�DjD1R'E'S7S Q I/El <br /> to Indicate E3 PARTNERSHIP ❑ STATE-AGENCY <br /> 1 1 J e El INDIVIDUAL El❑ COUNTY-AGENCY CY ❑ FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE� /, PHONE p.WITH AREA 7t <br /> � Ir U <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) (/!//V/ G�j— <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. it. ❑ III. ❑ <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 X AGENCY X FACILITY ID X X of TANKS at SITE <br /> 3y = = ooid /TC/ oba <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> CAC-r40 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> IC— <br /> THIS <br /> OCATION CODE CENSUS TRACT( ,l SUPERVISOR-DISTRICT CODE BUSINESS PSN❑ FILED NO ❑ DATE FILED <br /> HECK(III l) PERMIT AMOUNT <br /> U SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> BY: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 /> RM A(3-2-8B) <br /> DATA PROCESSING COPY <br /> ! x <br />