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STATE OF CALIFORIy.,� WATER RESOURCES CONTfVIL BOARD ' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> IF <br /> A. <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'IF°°l"` <br /> MARK ONLY ❑ I NEW PERMIT F__] 3 RENEWAL PERMIT n 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 ' <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME l - - CARE OF ADDRESS INFORMATION <br /> R'V(Gil/OA1 P 0 -e <br /> ADDRESS ANO <br /> STREET ✓Bw b+qup ❑ PAATN99IP ❑ STATE AGEA'GY <br /> / ClCORMTON ❑ LOCM-A*WD ❑ FEGEFAL AGENCY <br /> 9 S- 4I beM4 f- Sikorsk ❑ INDIVIDUAL ❑ CUIINIYAGENCY <br /> CITY NAME STATE Jj ZIP CODE SITE PHONE It.WITH AREA CODE <br /> 9910e 140- ,j CA - z -6#77Z <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTORPROCESSOR ✓Box if INDIAN EPA ID N _ M W TANK's <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GASS(ATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE M WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 13 <br /> erfv e <br /> NIGHTS: NAME(LAST,FIRST) III PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> N JO N to r" `S;"' <br /> MAILING or STREET ADDRE ✓Box 1 ndicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> C ❑ CORPORATION ❑ OCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2Z L �Q �� ❑ INDIVIDUAL V COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE <br /> ak d,.s C' q6;2t?;_ - <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEI . CARE OF ADDRESS INFORMATION <br /> t:F00 / d7d7lON ►)tints D� <br /> MAILING or STREET ADDRE ✓Box to indicate ❑ PARTNERSHIP ❑ TATE-AGENCY <br /> /� Q ❑ CORPORATION ❑ LOCAL-AGENCY Y7 FEDERAL-AGENCY <br /> �I7X r /J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> S4crampaf'o �SS2 rJ 6 SSI-3.288 <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. ❑ 11. ❑ 111. <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 R JURISDICTION R AGENCYII FACILITY ID S Al of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE R WITH AREA CODE <br /> Sc o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23.90 YES � NO <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT P BY: nn <br /> R) <br /> THIS FOAM 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 /> ORM A(3-2-88) 4 , <br />