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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 /> ao <br /> ( I COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 7 PERM C <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDEDPERMIT �6 TEMPORARY SITE CLOSURE 1D <br /> I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) <br /> FACIL <br /> ITY CARE OF DDRESS INFORMATION <br /> N REST CROSS Kt-ST ✓Bw loiMreR ❑ PAFiNEAB9P ❑ STATE AGENCY <br /> ADOD AON,,AE D 1CUM EM M Rol- Erv�Y <br /> - ' STATE ZIP DE FEE <br /> FEE ONE#.WITH AREA CODE <br /> CITY CA 1 Jy � <br /> TYPOISTRIBUTOR PROCESSOR ✓Box ifINDIAN EPA 10 N It uI TANK'S <br /> 5 O7HER RESERVATION aEl <br /> I J ll AT TX18 SITE Z <br /> ❑ I GAS STATION ❑3 FARM TRUST LANDS ✓`� 7� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE DAYS:� E(LAST,FIRST) PHONlA E WITH AREA CODE <br /> DAYS: NAME(EAST.FIRST) y A <br /> O( 01 PHON p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> sa <br /> 1A ELA <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF wDDRESS INFORMATION <br /> MAILING or ADDRE^�y , B to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ERA GENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITYNAMEyx A-44 STALE ZIP LADE PHONE N,WIT AREA CODE <br /> LL `7f <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> IA A44ftikel <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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: 1. D IL 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION p AGENCY p FACILITY IDM p of TANKS at SITE <br /> Effl 1 15 10 2,13 1 9,H 410 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> q Foo Nk <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHEOP <br /> N CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED I--I� DATE FILED /)p G <br /> YES NO Ifa !i� LI bl 1 0 <br /> 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 ...i <br />