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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD P { <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM " -o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ Fl-I ENTLY CLOSED SITE j <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 6V z <br /> 10 <br /> L FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACIF1ITE NAME ,/ 4NEAREST <br /> S INFORMATION <br /> ADDFjrSS�/ _ /I rA ;ET ✓Bow to iripwle ❑ PAfliN AG ❑ SfAERAGENENF�IIJJ N ❑ COAPOAAiION ❑ IOCNABDlL1' EgAL ENCYCoJ INOIvmOAI ❑ WUNW AGENO(CITY ME' ZIP ODE ITE PH NE N.WITH AREA CODE <br /> S"Z3(o <br /> TYPE OF BUSINESS: RIBUTOR ❑ 4 PROCESSOR ✓Box*INDIAN EPA ID N of TANKS <br /> E:jRESERVATION of AT THIS SITE B r <br /> 1 GAS STATION JZ 3 FARM E]5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) PHO p WITH AREA CODE DAYS N E(LAST,FIRST) PH E p WITH AREA CODE <br /> SY,� s <br /> NIGHTS' N EILAS FIRST) PHONE WITHAREACODE NIG : NAME(LAST,FIRST) PHO EB WITH AREA CODE <br /> 'Lc S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARED AQ ORES$INFORMATION <br /> MAILING gFET ADDRESS Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S ❑ CORPORATION ❑ LOCAL-AGENCYF DER -AGENCY <br /> 11 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM Sj5E'A ZIP CODE, /1 PHONIER Tf�AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> N /T�` <br /> NAME CARE AOR ESS INFORMATION <br /> MAILING 10 STREET ADDRESS Vbox to RATIle ❑ PARTNERSHIP 11 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY DERA AGENCY <br /> ❑ INDIVIDUAL ❑ PARTNERSHIP <br /> CITY NAM STATE ZIP C D PHONE N, AREA CODE <br /> S (J C) <br /> IV. LEGlwAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Eff, 11. ❑ 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 R JURISDICTION R AGENCY* FACILITY ID* *of TANKS at SITE <br /> ® = = 150 r Iq 1 10161011 <br /> CURRE LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE*WITH AREA CODE <br /> AAPS �I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> ODE CENSUS TRACT• SUPERVI R-0ISTRICT CODE BUSINESS PLAN FILED DAT FIL D <br /> zYES 0 NO � A �� Gt.MRMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> �_\YkORM A(3-288) S <br /> a� DATA PROCESSING COPY r <br />