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..n f. y <br /> �OF^ <br /> STATE OF CALIFORNN WATER RESOURCES CONTROBOARD fyE °•°K,..r F <br /> WP•• ��A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SATEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - _, �� 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE OF— <br /> F <br /> F- F <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> ^4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 'p <br /> C� <br /> FACILI ITE NAME CARE OF IDDRESS INFORMATION <br /> AD NEAREST CROSS STREET �✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 3s—/ Id'CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 1k-d QZ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME . STATE ZIP CODE SITE P ONE#,WITH AREA CODE <br /> a <br /> CA qs Z�� (.2-617 <br /> TYPE OF BUSINESS: [jR'fD(STRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID# <br /> RESERVATION or #of TANK's <br /> E] 1 GAS STATION ❑3 FARM ❑5 OTHER • TRUST LANDS ❑ �/I� AT THIS SITE r <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FI T) PHONE#WITH AREA CODE DAYS: NA E(LAST,FIRST) PH NE#WITH AREA CODE <br /> A <br /> NIGHTS: N E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:Lo� <br /> E(LAST,FIRST) PH NE#WITH AREA CODE <br /> t m)T6�--7y m <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE ADDRESS INFORMATION <br /> LING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> // CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY/J�� <br /> lam/ !3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CA 9S <br /> ITY NAME STATE ZIP CODE PHONE ,WITH AREA CODE <br /> ?-q <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIN6 or STREET ADDRESS �✓ to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> fs CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El-INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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. ❑ if. 0, 111.❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 � E610 I 13 1 / DD10/19� <br /> CURRENT LOCAL AGENCY FACILITY ID# APPRO D BY N E PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS RAC-T k SUPERVI OR-DISTRICT CODE BUSINES'PLAN FILED DATE !ro ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORM A -2-88) <br /> DATA PROCESSING COPY <br /> s� S <br />