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STATE OF CALIFORNIA v WATER RESOURCES CONTROL BeARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY IJ" ' NEW PERMIT 3 RENEWAL PERMIT F ,;HANGE OF INFORMATION 7 PERMANENT OSED SITE FJ <br /> ONE ITEM � 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I 6 ( Imo,, <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAVn�^,oA/� CARE OF ADDRESS INFORMATION <br /> ADDRESS L[�E NEAREST CROSS STREET ✓ vdaaN, 0 PARTNEASRP 0 STATE AGENCY <br /> /7o APORAi10N 0 LOCA AGENCY 0 FEDEW AGENCY <br /> ❑ INOIVIOUAL 0 COLNtt AGENIX <br /> CITY NAME STATE ZIP CODE ITE PHONE p,WITH AREA CODE <br /> CA C/ .73 v <br /> TYPE GF (NESS 2 DISTRIBUTOR 4 PROCESSOR I/Box if INDIAN EPA ID # N of TANK'f <br /> 1 GAS STATION ❑ 3 FARM RESERVATION or ❑ AT THIS SITE �J <br /> 5 OTHER TRUST LANDS <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 /> Gr/ - d <br /> NIGHTS: NAME(LAST, RST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to"ic"Ie 0 PARTNERSHIP 0 STATE-AGENCY <br /> LJ C�pRP(RATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> OIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B°x to,nd,cele 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. Rr11. E:1 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 a JURISDICTION N AGENCY R FACILITY ID Ar B of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS 7TRR7ACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D 6 YES NO -L <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> OZTHIS 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 (3-2-88) r <br /> �, DATA PROCESSING COPY <br />