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STATE OF CALIFORNSO WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Ike <br /> MARK <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMA SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> Qn <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) rn <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> GC[L- <br /> ADDRESS r NEAREST CROS,STRUT ✓BwloiMicak 'PARNEASHIP ❑ STATE AGENCY <br /> V/LI/.�/� ❑ DN ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> 0?/ .,7 <br /> be. IVICIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> LindP.� CA C sd slo <br /> TYPEO ELISINESS: ❑ 2 DI R ❑ 4 PROCESSOR INDIAN EPA ID n Mof TANK'F <br /> ESERVA <br /> ❑ 1 GAS STATION FARM E] 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> S6 4 -w-- , s <br /> NIGHTS: NAME(LAST,FIR ) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> �/�a,_24� G4- bei r7 C T <br /> MAILING or STREET ADDRESS ✓Boxl tale 11PARTNERSHIP ElSTATE-AGENCY <br /> e� ❑ PORATION ElLOCAL-AGENCY ❑ FEDERALAGENCY13 q" Q/ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STAT 4 ZIP E 3 (0 PHONE p.WITH AREA CODE <br /> t7q We <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S A � <br /> MAILING or STREET ADDRESS ✓Box to ale Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ IL ❑ If. ❑ <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 M JURISDICTION M AGENCY M FACILITY ID M M of TANKS at SITE <br /> d <br /> CURRENT LOCAL AGENCY FACILITY IDNAPPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER FF R�/PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> I 33C1�--. YES E] NO � 6r', Y_ y <br /> / CHEICK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIII BY: <br /> •]I'A•V// THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIONONLY. <br /> FORM A I3-2-SB) <br /> DATA PROCESSING COPY <br />