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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM =`° o <br /> SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONzi <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY � NEW PERMIT F-13 RENEWAL PERMIT ®,.,5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Z <br /> 1® <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SRE NAME CARE OF ADDRESS INFORMATION <br /> I L FiS_r& FL N <br /> ADDRESS NEAREST CROSS STREET B.m MiRite D PARTNERSHIP D STATE AGENCY <br /> S-r LAS o INcivouk 0 COOIINTY AG>EENCY NCY D FlD RALAGEN Y <br /> CITY NAME �E /' STATE ZIP CODE SITE PHONE p,WITH A DE <br /> s �I� CA Y�7�O6 Z19 <br /> TYPE OF BUSINESS: ❑ 2 DI BATOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID It y of TANK"a <br /> 1 GAS STATION ❑3 FARM S OTHER TRUSTYLANDS ATION or ❑ *RTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY,) <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA COD DAYS. NAME(LAST.FIRST) P NE p WITH AREA CODE <br /> N $L M f-/V cto NGA 7S`1�3T La, 3133 <br /> NIGHTS. NAME(LAST FIRST( PHONE p WITH AREA CODE MERITS. NAME(LAST.FIRST) ONE p WI ,CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) <br /> NAME S f, A-5 fl"BOv� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS V ^J GA- ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> /jFZAjR ,S D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> INDIVIDUAL CI COUNTY-AGENCY <br /> CITY NAME Ie✓ ✓V_'-' ' C fill y,��Z V STATE ZIP CODE PHON;It,WITH AREA CODE 33 <br /> Ill. TANK OWNER INFORM TION & ADDRESS — (MUST BE COMPLETED) V <br /> NAME CARE OF ADDRESS INFORMATION CiR <br /> / 3 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D STA -AGENCY <br /> 'qPRORATION D LOCAL-AGENCY FEDERAL-AGENCY <br /> Lel D COUNTY-AGENCY <br /> CITY NAME n�� STA E ZIP CODE WITH EA CODE <br /> IV. LEGAL NOTIFICATIONAAN6 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 N PRI ED&SIGNATUR I DATE <br /> . <br /> LOCAL AGENCY USTE ONLY <br /> ,- moi/ I CO�UNTTYY�# JURISDICTION# AGENCY k FACILITY ID a p' p of TANKS at SITE <br /> I = V 2 /� S p <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE If WITH AREA CODE <br /> dr, 32. <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOP-1-0`xr CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE F LE <br /> J n ?J gO z O YES [:] NO g'C' <br /> CHECK r PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 113'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3 2-88) <br /> tY /^—GQ �"�': DATA PROCESSING COPY <br />