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f SE�,�u..sa"rye <br /> OF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD .. „ <br /> A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> x k <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Cq(fFpprP +Q <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONNTLY CLOSED SITE N7? <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE cm <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NA WE l �� <br /> NEARESTCR055TREET LNEAEIP <br /> ADDRESS Cl CORPORATION d OCAAGNCYp FEDERAL-AGENCY <br /> _ <br /> ❑� IN01Y1O11AL Q COl1NTY-AGENCY <br /> STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CITY NAME CA s 7� <br /> */Box i INDIAN EPA ID p ✓✓ q of TANK's <br /> TYPE OF BUSINESS: ❑ 2 DISTRI9UTOR ❑4 PR SSOR ESERVATION Dr AT THIS SITE <br /> ❑ I GAS STATION ❑3 FAflM OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) (EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) �. PHONE k WITH AREA CODE DAYS'. NAME{LAST,FIRST) <br /> ' PHONE#WITH COD <br /> oo <br /> 1. <br /> NIGHTS: NAME(LAST.FIRST) PHONE b WITH AREA CODE NIGHTS', NAME(LAST IRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME - — <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE•AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Q FEDERAL-AGENCY <br /> INONIDUAL Cl COUNTY-AGENCY <br /> STATE ZIP CODE PHONE k,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS (� ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p.WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE{7}BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: r <br /> THIS FORM HAS BEEN COMPLETED UNDER PFN41_ry^' 05755 <br /> CORALLO - MOODY,INC. <br /> ,--DescriPtion— <br /> - 263a4S�RTEYpRfE i <br /> --I�,voicn. FEE <br /> �--+-- <br />