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STATE OF CALIFORNL.r WATER RESOURCES CONTROwtOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w r Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `+�„o;„_�P 10 <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM Y CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ~ <br /> 6 TEMPORARY SITE CLOSURE �( <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) tom+ <br /> FACILITY/SITE NAME 6wk /� CARE Of ADDRESS INFORMATION N <br /> ADDRESS I _ / PSA` NEAREST CROSS STREETigKaw 13 PARTNERSHIP ❑ FATE.A39C( <br /> • 1 V�,� ��/l4fA 7ON ❑ LOCAL AGENCY ❑ FEDERALLY <br /> -ACEN <br /> ElINONIOUCdAI 0 Im Aoi <br /> CIN NAME in STATE ZIP C E S E PHON It.WITH REA CODE <br /> atl< dVi CA S'2®S� u4 �Z-3�o <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box i/INDIAN EPA ID a <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER TRUSRESETLANDS <br /> ATION or ❑ - A/�-s/ AT THIS SITE/FU N'� AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE At 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 /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME / i_,D ��� �/ CARE OF AD ESS INFORMATION <br /> MAILING or STREET ADDRESS Q ox 0 0 to indicate PARTNERSHIP STATE-AGENCY <br /> CRPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME / STATE 2IF CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME r^ e _ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE it,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. ❑ 11. 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 N JURISDICTION N AGENCY N FACILITY ID B N of TANKS at SITE <br /> 10 1 U2- 3 1 vrlao � <br /> CURRENT LOCAL AGENCY FACILITY I0 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> L E� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED pIAZ <br /> '0 YES ❑ NO 1[:] ' (` <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> W// //'dod` <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-9B) J <br /> w DATA PROCESSING COPY mall <br />