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-: STATE .OF.CALIFORN" 1�-�. <br /> WATER RESOURCES CONTROL BOARD <br /> FORM OA,. �I <br /> UNDERGROUND STORAGE-TANK PROGRAr <br /> SITE FACILITY/SITE,'INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE ��c,FORN P <br /> f <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT S CHANGE OF INFORMATION j40 <br /> 7 PERMANEN ITE <br /> ONE ITEM . : ❑2 INTERIM PERMIT ❑E AMENDED PERMIT ❑ I. <br /> TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) r 0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION f <br /> ut4�n <br /> ADDRESS � t NEAREST CROSS STREET ✓Bawd -lit ❑ PMIMEW ❑ STATE-AGM <br /> AZ N trCM Q� 'i 11CUWMTM El t.Gs14WO ❑ FHOK-M MLY <br /> S'r <br /> FR �►n ❑ IMOMDUAL ❑ CUM-COICY <br /> CIT(NAME 6Tk c'°` STATE II ZIP CODE <br /> 1 , SITE PHONE p,WITH AREA CODE <br /> CAII y6:z&5 <br /> TYPE OF BUSINESS: ❑ 2 OISTR WTOR [k 4 PROCESSOR ✓Box i1 INDIAN EPA ID p°� <br /> ❑1 GASSTAKs <br /> TI�I ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ATIONor ❑ t LAG) 000 15� 1�� AT THof IS SITE rL <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: ,NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE W WITH AREA CODE <br /> E .. �C+ 1'LAI �I <br /> NIGHTS. NAME jLA9T,FIRST) PHON fi9I H AREA CODE NIGHTS:, NAME(LAST,FIRST) PHONE M WITH AREA CODE g <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BEFCOMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to Inoioale ❑ PARTNERSHIP ClSTATE-AGENCY <br /> d5- <br /> I_ AV Ie L H r 7V#4 ES L�D CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IO C7 WINDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 1.DS SLS G4. I q a o c3- 7.� 9 f; <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AM AA ANIRSOLAEs- <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY y <br /> CITY NAME STATE' I' ZIP CODE } PHONE I$,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS ! <br /> CHECK ONE(#1AOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING:I 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 /> �s <br /> APPLICAN ' NAME(PRINTED&SIGNATURE) DATE ' <br /> 45 AA e <br /> LOCAL AGENCY USE ONLY <br /> COUNTY.,* JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 4 <br /> CURRENT LOCAL AGENCY FACILITY ID t APPROVED BY NAME PHONE•WITH AREA CODE <br /> LPERmrrwu0bsm PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> N COD_E CENSUS TRACT Il SU1'ERYISOR-DISTRICT CODE BUSINESS PLAN FILED " DATE FILE <br /> `+ YES ❑ -No D 9'��9 <br /> CHECK i PERIFITAMOUNT SURCHARGE AMOUNTFEE CORE RECEIPT R BY: <br /> THIS FORA MUST SE ACCOMPANIED BY AT LEAST(1108 111ORE TANK PERMIT FO RM 'B'APPLICATION(S), UNLESS THIS IS KCHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-M) 'I. <br /> DATA PROCESSING COPY ` <br /> ,r <br />