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T... . <br /> . . <br /> STATE OF CALIFORNM? WATER RESOURCES CONTROBOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMo Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IJ <br /> ONE IT ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> al Cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) W <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> Ma 4,f <br /> AIS <br /> ADDRESS NEAREST C SS STREET ✓Bal loiMPale 0 PARTNERSHIP 0 VATEAGENLY <br /> r+ _) �OPP011ATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ,�l , a �{[iT f ter d'INolvlouA ❑ COUNIYAGENY <br /> CIN NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> er Nk CA 536x7 207-W-3.21%0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA ID n #of TANK's <br /> ❑ ESETION <br /> I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS dr ElAT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHT : NAM (LAST,FIRS PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Al; P43 i 209 B69 3.2a/0 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L as <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE At.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME T CARE OF ADDRESS INFORMATION <br /> fs's y <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: I. it. ❑ 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 /> COUNTY41 JURISDICTION K AGENCY K FACILITY ID# 0 of TANKS at SITE <br /> ENT LOCAL ENCY FACILITY IDM APPROV NAM PHONE M WITH AREA CODE <br /> R c 1 a3 <br /> AL DATE PERMIT E%PIRATION DATE <br /> LOCATION CODE CENSUS TR T# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1 23.LTO �26 YES NO b'/�fi/89 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> C's <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 /> FORMA(3-2-88)�((/ <br /> 9'I 1V / a DATA PROCESSING COPY • <br />