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STATE OF CALIFORNIAr' WATER RESOURCES CONTRdr'BOARD <br /> e«` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> n <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o t o <br /> (.� COMPLETE THIS FORM FOR EACH FACILITY/SITE °q��.oaw"' <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWAL PERMIT ET5 CHANGE OF INFORMATION ❑ TLYCLOSED SITE F-4 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FA /SITENA E r� VA <br /> AR ADDRESS INFORMATION <br /> AD RESS N REST OSS STREET ✓yMb nOc,W ❑ PARMEMIP ❑ STATEAGENC <br /> / 1 WAPOAATION ❑ LOCPLAGBO ❑ FEDERALAGEWY <br /> -3 33 ❑ INDVIOUAI ❑ NUIVYAGENC <br /> CITY NA ( STATE ZIP CO SITE ONE N,WITH AREA CODE— <br /> '01 <br /> CA <br /> 2 / L _ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ /WaSSOR I '/Box it INDIAN EPA ID <br /> RESERVATION❑ a <br /> 3FARM _ AT THIS SITE <br /> r / p M TANKS j <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D S: NAME(LAST,FI ) PHO i WITH AREA CO DAYS�;W(LAST,FIRST) PH E N WITH AREA CODE <br /> NIGHTS: NAM (LAST.FIRST) I PHONE N WITH AREA CODE NIGHT AME(LAST,FIRST) P ONE N WITH AREA CODE <br /> A o9 LZ6 A A j <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CAREOF DDRESS INFORMATION <br /> MA Gor STREF/�T�ADDRESS ,IV✓ zA' indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> • / dV 3 ! ❑ INDIVIDUALION 1:1 LOCAL-AGENCY❑ COUNTY-AGENCY <br /> ❑ FEDERAL-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE#, ITHAREACODE <br /> /� C/A d <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME .�^ /] _ CARE OF ADDRESS INFORMATION <br /> j MAILING or STREET ADDRESS ✓BO%to indicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> i <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDIIESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL Ill.❑ <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 If AGENCY# FACILITY ID It #of TANKS H SITE <br /> a] = 1 ,010 I o <br /> CURRE�NIT�LOfCAL AGENCY FACILITY IDN APP110YED BY NAM PHONE kYIITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE MI EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVIS -DISTRICT CODE BUSINESS PLAN FILED DA FILED <br /> b YES NO ! <br /> CNE N 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 /> FORM A(3-2881 <br /> DATA PROCESSING COPY .N/ <br />