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STATE OF CALIFORNIA • WATER RESOURCES CONTROL JWRD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> F. <br /> SITE. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO <br /> �'1lll Oxil�' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE � � <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FAG4ITY/SITE NAME <br /> L s S� <br /> AOONESS NEAREST CROSS STREET gEA <br /> AGDYX ❑ DNAf#N.TC �, ` STATE ZIP CODE ,WITH AREA CODECITY NAME CA�� « EPA IO YttPE OF OUSINESS. ❑2 DISTRBUTOfl ❑ PROCESSOR ✓Box d INDIAN _ TANK YRESERVATION w ❑ TN18 81TEn I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDSEMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PY)DAYS. NAME(LAST.FIRST) PHONE Y WITH AREA CODE DAYS. NAME(LAST,FIRST) ONE Y WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS NAME(UST.FIRST) HONE Y WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST INFORMATION <br /> BE COMPLLETED) <br /> CARE OF ADDRESS <br /> ENAMEC'of STREET ADDRESS Bax toin0icate ❑ PARTNERSHIP ❑ STATE-AGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDEML-AGENCY <br /> % I1 /CINDIVIDUAL ❑ COUNTY-AGENCYVSTATEZIP CODE PHONE Y,WITH AREACODEME TE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> C /F LGml� <br /> MAILING w STREET ADDRESS ✓Sox to'ftcale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ NDN DUAIION a LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE Y.WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOE INDICATING WHICH ABOVE ADDU"SHOULD 0E USED FOR BOTH LEGAL NOTIFICATION AND SILUNG: L ❑ IL ❑ IK❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORREC r.. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) <br /> �t <br /> LOCAL AGENCY USE ONLY <br /> AGENCY E 6B B DI TANKS SI SITE " <br /> COUNTY Y JURISD�� <br /> 3 9 = � ° �-� . < p C c L <br /> APPROVED BY NAME PHONE Y WITH AMA COOS <br /> CURRENT LOCAL AOlNCY FACILITY ID Y <br /> 'S <br /> PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> __ _ BUSINESS PLAN FILED DAT!FMD <br /> LOCATIO[NN CODE CENSUS TRACTY WPERVISOR•O18T1UCT COO! YES ❑ NO El <br /> K / � T 3 2 ■Y: <br /> RcalnY a/yo Y <br /> CHECKY PERMIT AMOUNT SURCHARGE AM RE COD! C, o <br /> THIS FORM MUST SE ACCOMPANIED BY AT LEAST(1)OR YORE TANK PERSST FORM 'B' APPLICATIOIIIS).UNLESS THIS IS A CHANGE OF SITE INFORMATION 0��� <br /> rUhM A13.1 WI <br />