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1 11 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL RD ', 1 44 ' <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `"'•a•"'' <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E7115'CHANGE OF INFORMATION ❑ 1 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT- ❑ A AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G s a S <br /> ADDRESS NEAREST CROSS STREET ✓BooL.srr, D EAARMV ❑ STATEAGENCf <br /> 0 COREWTON D LOCAL ❑ ROEAN AGRO <br /> 0MWM [3 CUM AWO <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> Cs.Tkca CA <br /> TYPE OF BUSINESS: ❑2 DISTRBUTOR ❑N PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or BT TS SI <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS <br /> SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I /ea�e La <br /> MAILING or STREET ADDRESS ✓Boa to md1cale ❑ PARTNERSHIP D STATE-AGENCY 1 <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY I\ <br /> �p 7 3 /v i Mx ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> /0 c' &P to <br /> III. TANK OWNER INFORMATION b ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Box to inGictfw D PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADONIS:SHOULD BE USED FOR NOTE LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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(POINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY E JURISDICTION E �AGENY## FACILITY ID B S of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE 1 WITH AREA CODE <br /> 1- 1-9 s �L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> _ O y o2 3 YES E] NO El (' <br /> CHECK IT PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECRIFTI BY. <br /> C o 10 <br /> THIS <br /> !0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY�\ <br /> EOHM A IJ-1 Wj c `6 <br />