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I F <br /> F � k <br /> STATE OF CALIFORNIA k,.J' WATER RESOURCES CONTROL�.4RD � `�� < g`'•� "� <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> ® a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> COMPLETE THIS FORM FOR EACHF CILITY/SITE °�L",pr n <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ED <br /> _LtERW&jgNTLY CLOSED SITE <br /> ONE ITEM ❑.2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S (' <br /> I. FACILITY/SITE INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADORESS INFORMATION <br /> ADDRESS XfJ <br /> v N CRSSTREET FWDU&W ❑ STATEAam <br /> E ❑ RER �G <br /> YON41-(,yI. aXlI -AGNCY <br /> CITY NAME STATE ZIP COOS SITE PHONE N,WITH AREA CODE j <br /> L �-�,•L. cA Sa,� o <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓ft.it INDIAN EPA ID n f <br /> RESERVATION of FSOTANICs <br /> ,❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS � THIS SITE <br /> i <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE I <br /> I ' <br /> NIGHTS: NAME(LAST,FIRST) HONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Of WITH AREA CODE ' <br /> 11. PROPERTY OWNER INFORMATION & AD KESS - (MUST BE COMPLETED) <br /> j4 <br /> NAME CARE OF ADDRESS INFORMATION <br /> films a ,f�e� <br /> - MAILING or STREET ADDRESS ✓Banc to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> -� ❑ ,pMPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 671 NDIVIDUAL ❑ COUNTY-AGENCY <br /> � CIN NAMEC / V T � STA � ZIP CO�� �O PHONE M,WITH AREA CODE , <br /> `P C <br /> I III. TANK OWNER INFORMATION &ADDRESS -- (MUS E COMPLETED) <br /> NAMEr � RE OF ADDRESS INFORMATION j <br /> MAILING or STREET AD ESSt ✓B o' dicate ❑ PARTNERSHIP ❑ STATE-AGENCY i <br /> / 001 ❑ C RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> pIVID L ❑ COUNTY-AGENCY <br /> CITY NAME _ STATEn -IP CODE PHONE$1,WITH AREA CODE <br /> C14 <br /> IV.':LEGAL NOTIFICATION WND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION Ahu LALLING: 1, ❑ II. ❑ IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOvvLF_DGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 14 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FEAGENrC' <br /> JURISDICTION• AGENCY N FACILITY ID 0 of TANKS at SITE <br /> Dul 1 1 1 j E , 1 .1 loljlcLl�il/l FTC) <br /> FACILITY i0 APP1ROV q BY NAPE PHONE N WITH AREA CODE <br /> Co <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> NSUS TRA IF SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> t YESNOERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT I BY: <br /> THIS FORA MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> RM A(3.2-881 <br /> ,i <br />