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/SE�•au Ov1'�..f <br /> STATE OF CALIFORNI11 WATER RESOURCES CONTROBOARD <br /> FORM`A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE vFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE10 <br /> —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> F-� <br /> FACILITY/SITE NAME0 CARE OF ADDRESS INFORMATION <br /> Cv <br /> ADDRESS NEAREST CROSSSTREET ✓kxtohdiak ❑ PARTNERSHIP ❑ STATE AGENCY <br /> El( (/LI ❑ INDIVIDUAL ❑ CAUNWAGENI,1' FEDERAL AGENCY <br /> CITU NAME S7a 1 .� STATE A 21PDE/ SITE LJ'N.WITH AREA <br /> CODE <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IID If /G 9#of TAANSK's <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYATION LANDS of ❑ AT THIS SITE <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 /> Koo - to G�s'7 � <br /> NIGHTS: NAME( ST,FIRST) PHONE k WITH AREA CODE NIGHTS. NAME(FAST FIRST) PHONE N WITH AREA CODE <br /> At ti <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME n- / SII j CARE OF ADDRESS INFORMATION <br /> SIG CAIZM ICk- 4 <br /> MAILING or STREET ADDRESS ® ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE L-93 ZIP CODE I� P �✓<IITH ARE / <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED)/JS <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> yy ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. V 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> a III t 1 o0oi <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> h/1 c C.0 jz. 12_ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK#� <br /> CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> l -7 � YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 44,11119 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) <br /> DATA PROCESSING COPY 44 \J <br />