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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> V �-1 <br /> FARM `A': UNDERGROUND STORAGE TANK PROGRAM 7 `�� �p <br /> �1TE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' , a <br /> 0 <br /> (PI <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ZIERUANiNTLY CLOSED SITE 1-& . <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ,-4 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS--(MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET b lArale ❑ PARTIGOW ❑ STATE-AGBILI' <br /> CGI�OAATIpS 11LOG1L.hG91(.Y ❑ FEDQiAI-AGBR,Y <br /> ' ❑ MYI K ❑ wam-AGRcy <br /> CITY NAME STATE ZIP ODE SITE PyOgE .lf,WIFH AREA CODE <br /> lJl1{C/- <br /> 77 OF BUSINESS: ❑2 D1STNLROR ❑4 PR R EW U NDIAN EPA ID# 80TTAN" <br /> RESERVO❑ 1 GASSTATION ❑3 FARM El OTHER TR LANDS or ❑ A7 THIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM ( ,FRST) PHONE#WITH AREA <br /> �CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> V <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION&ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �t <br /> MAILING or STREET ADDRESS V96tcidillo ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME: � CARE OF ADDRESS INFORMATION <br /> a/W R <br /> MNLING rn STREET ADDRESS 111115ux to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br />' CRY NAME STATE ZIP CODE PHONE N,WfTH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOYB ADDRIU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. it. ❑ 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 /> k <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION# AGENCY E FACILITY ID# E of TANKS at SITE <br /> 171y] I-01clo <br /> CURRENT LOCAL A7CY FA 1 D N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONDE CRNSU8 TRACT# SUPERYiSOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> `el 2 YES rl . NO [:] —'� <br /> C <br /> 6 HECK# PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT N BY: <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 /> FARM A(3.2.88; <br /> DATA PROCESSING COPY <br />