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/ys -ate -zz <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD F <br /> 1 , <br /> RM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> m COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ff�?GHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> =01 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> AAIS01v 6&-(s 61JIU& <br /> ADDRESSp/� NEAREST CROSS STREET ✓ - N ❑ Fa NEAS1IP F] STATE AGENCY <br /> //O V R% ❑ LOCAL AGENLY ElFENW AGENCY <br /> ❑ NW ❑ WIINIY-AGENCY <br /> CITY NAME STATE ZIPCODE SIE PHONE N WITH AREA CODE <br /> CA ZV <br /> TYPE OF BUSINESS: ❑ 2DISTRIB OR ❑ 4PROCESSOfl I ✓Box d INDIAN EPA ID N Not TANK'a <br /> ❑ I GAS STATION ❑3 FARM ❑.SER TRUSTVLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> r evlr oy � -//7y <br /> NIGHTS. NAME(LAST,FIRS ) PAONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME / z�- a� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / O C3 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ;K-fro7 PHONE N.WITH AREA CODE <br /> V <br /> III. TANK OWNER INF RMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> -7— <br /> MAILING or STREET ADDRESS ✓Sox to intlicaie ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ 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. II. ❑ 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 N AGENCY N FACILITY ID N N of TANKS BI SITE <br /> ® = / E= 10C) O Z <br /> CURRENT LOCAL AGENCY FALL IDN APPROVED BY NAM PHONE R WITH AREA CODE <br /> PERMIT NUMBER Z PERMITAPPROVA DATE OAMIT EXPIRATION DATE <br /> 9� <br /> LOCATION CODE CENSUSTRACTN PER 1 R-DISTRIC CODE BUSINESS PU1NFILED ❑ DAM FV <br /> 9 YES NO ISY <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 ONL <br /> �A FORM A(3-2-88) <br /> 'v ,%W DATA PROCESSING COPY <br />