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STATE OF CALIFORA WATER RESOURCES CONTIN BOARD <br /> „ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM V � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> F7MARK,ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMgTION 21�7 PERMANENTLY CLOSED SITE I"A'EM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I —4 <br /> w <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A <br /> O <br /> FACILITY/SITE NAME LL�� C - CARE OF ADDRESS INFORMATION <br /> T�D % - A P r4 h"r R O SSkJJzx- <br /> ADDRESS NEAREST CROSS STREET ✓klMr Ai¢te ❑ PAIRNEASHE ❑ STATE AGEND <br /> 11 O�S� ( I OtiIR -(-�-e-� ❑ INDIVIDUAL <br /> ID❑ COGI1N'RAGE CY AGEN(Y ❑ FFDEAALA@END <br /> CITY NAME STATE ZIP CODE SITE PHONE a.WITH AREA CCODE//�`..KK, <br /> Cz CA qS33,c) 09 3% Z99L <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER RESERVATION <br /> or ❑ �— M of TANK's <br /> TRUST LANDSATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA!Vj jr (1 u ST,FIRST) r PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE it WITH ARFCODE <br /> c�55 f tt� 20 X38 299(� <br /> NIGHTS: NAME(I-AST,FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.dedicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ^� CARE OF ADDRESS INFORMATION <br /> .%c <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION k AGENCY M FACILITY <br /> (/IDD�At TT N of TANKS at SITE <br /> l!J S V <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE <br /> Rosseas <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / <br /> LOCATIOf(CQDE CENSUS iPl1CT SUPERVISOR-DL IC( C BUSINESSFILED NO <br /> ❑ TE FILED t <br /> CHECK k (,j` PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At SBY: <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-BB) 0 ✓ <br /> DATA PROCESSING COPY <br />