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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD l <br /> w_ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED SITE � <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) DILY D Cull <br /> FACILITY/SITE CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET <br /> ❑ PRF [I FATEAGENCi <br /> M¢ 11 LOCAL AGENCY [I FEDERAL ACE4 <br /> ,Y <br /> 1 ❑ INDNIOUN. <br /> ❑ caurmacencr <br /> CITU NAME STATCA ZP QQ� SITE PHONE It, AREA COD_ E, <br /> &IL <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOR ✓Box iI INDIAN EPA ID p At of TANK's <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS <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 /> �JIM 1260 <br /> A=(LAST, ) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> O <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �e <br /> Y�061AJ(,( ' <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 3 Q CgRit4bRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> g.LMDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COPES PHONE a,WITH AREA CODE <br /> /LL <br /> III. TANK OWNER/INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CNECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. ❑FIII.❑ <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 /> COUNTY# JURISDICTION# AGENCY# FACILITY-ID:#— _ #of TANKS at SITE <br /> ff2tjCY FACILITY ID# \ APPROVED BY NAME PHONE#WITH AREA CODE <br /> 061 <br /> - --\ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ENBUS�TRA M BUPERVISON- ICT CODE BUSINES;PLSN FILED NG ❑ D��ILEO dl <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> ` , l FORM A(3-2-BR) 101000—co <br /> DATA PROCESSING COPY <br /> Ioj(SIOn <br />