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STATE OF CALIFOR IR ' <br /> WATER RESOURCES CONT L BOARD w`•'"'``'`�` <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " �o ••� <br /> SITE /� , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ca <br /> V COMPLETE THIS FORM FOR EACH F ILITY/SITE `'��•�a"" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) OD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> uNev,.i yCE <br /> ADDRESS <br /> A NEAREST CROSS STREET S.ondole ❑ PARTNERSHIP 11 STATE <br /> C1 CORPORATION 11 LOCAL ❑ FEDERAL <br /> Y_ uN/u �,&_014 ^-ti M <br /> ❑ COUN7 AGENCY <br /> CITY NAME ! 1 Y+� L•� STATE ZIP CODE f SITE PHONE#,WITH AREA CODE <br /> o CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ LAG -0 V O 1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA OODE <br /> NIGHTS: NAME ILA T,FIRST) PHONWRH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE WITH AREA CODE <br /> 3 1'' (�'ls-L:2Z7 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ni U.:1 ICG coir <br /> MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �G 16 CORPORATION LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> /, WA,,5t1f''4 #-n'4 BLVD <br /> INDIVIDUAL El COUNTY—AGENCY <br /> CIN NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> J.06. A4461eLGs 9y�G <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> wLiki <br /> MAILING or STREET ADDRESS ✓Box to indicate O PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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 BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. XJ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICAN ' NAME(PRI PITIED&SIGNATURE) DATE <br /> c ° G y+ vf49 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [�H] = ,;)_ qI I I jq <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> KION y� <br /> PERMIT NU ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED <br /> 3 1K 3 .1 YES NO o /(�9 <br /> CHECK# PER IT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> G THIISS F'XORM 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 /> M A <br /> i <br /> \R T/(S/2 <br /> \ <br /> • DATA PROCESSING COPY <br />