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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•�""'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ Z PFRMAg TLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑S TEMPORARY SITE CLOSURE 0 LE2 1 ] <br /> I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) ~ <br /> OD <br /> FACILITY/SITE NAME ^ CARE OF ADDRESS INFORMATION <br /> Cof <br /> ADDRESS 1 l NEAREST CROSS STREET ✓Bmbifiab ❑ PPiNDW ❑ STATE-AGENC <br /> YnIl / So COWMTKIN LOCAL-AGENCY <br /> -7 J , 1 'e/ f I L Cl COUNTY MENC <br /> CITY NAME �� - L w STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> (/A CA vle— <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 ROCEMR ✓Box if INDIAN EPA ID # #of TANKS <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUSTYLANDS or❑ AT TXI881TE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE DAYS' NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Wood s}zv FIZ/9'NkI�— <br /> NIGHTS: NAME(LAST,FURSTY PHONE#WITH AREA CODE NIGHTS. NAME(LA ,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to i,dicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �/a ❑ CORPORATION 13LOCAL-AGENCY ElFEDERAL-AGENCY <br /> F V d �O 2— ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> S7rvGts_'7o rJ 6.14- 1 &7_s-g_01 <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sltiw12 A5 <br /> MAILING m STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> l ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE HONE#.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. IS.❑ <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 If AGENCY# FACILITY ID If #of TANKS a1 SITE <br /> 1610 21 aO 10 1 / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> GF _r r-;:_ _? <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �L-3�V v 2,0 YES E] NO 3-Z-$ <br /> l CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BYlNF,/1�S <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 /> WI FORM A(3-2-88) <br /> DATA PROCESSING COPY J <br />