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STATE OF CALIFORN 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 EA7 FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> OVI NE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6TEMPORARY SITE CLOSURE <br /> Cm <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> :-�fajve A14 =900 020(d rkI <br /> ADDRESS NEAREST CROSS STREET I/SIP loindmile D PARTNERSHIP D STATE AGENCY <br /> ,'I / D CORPOMTION Cl LOCAL AGENCY 1:1 FEDERAL-AGENCY <br /> 322 N tV1AV&r D INDNIDUAL D WUNIY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> n1 I�I CA OS -.? 3`7 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR v l 4 PROCESSOR ✓BOx H INDIAN EPA ID # #of TANK'# <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESERVATION or 1:1 <br /> A77HI5 SITE <br /> TRUSTLANDS <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 /> — -2 utas 249- 1 - / <br /> NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF EGRESS INFORMATION <br /> in Che -whirl <br /> MAILING or STREE ADDRESS -/Box to ind,c e D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 3 D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> '7314711 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP Cl STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. Ef I. ❑ Ill. ❑ <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 If AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> E <br /> \ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT* SUPERVISOR-DIIXTRIC7 CODE BUSINESS PLAN FILED DATE FILED <br /> 323 res ❑ No ❑ '/Z 19 L <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: I# <br /> V J) rJJJA <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST!"nR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNI,'',;S THIS IS A CHANGE OF SITE INFORMATION ONLY. 41 <br /> FORMA(3-2-88) -0 <br /> DATA PROCESSING COPY <br />