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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 APPLICATION 10 <br /> 10 <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMITE�f<CHANGE OF INFORMATION ❑ 7 PERMAN CLOSED SITE I"a <br /> ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> c vN �ASAQCE G <br /> ADDRESS S NEAR ST CROSS <br /> PMN1P <br /> ❑ ❑ STATE AGENCY <br /> l� oomAGENCY ❑ ROLw-p3Flx <br /> Y <br /> Noo/v60 LOCAL <br /> CITY NAME ��� STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DIURIMOR ❑ PROCESSOR ✓Box if INDIAN EPA ID # <br /> E:] 1 GAS STATION [—]3 FARM 5 OTHER TRUSTMLANDS ATION dr ❑ #of TANK'N <br /> AT THIS SITE a <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> &nnqM/%le ZO - W3-SS" 8 .mono, <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LA .FIRST) PHONE N WITH AREA CODE <br /> Z/ ell & !/ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ^6: -�- C_ / /Y L CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ,DO�S (//I�T� P�%/ (wn-w_ 17 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1( 1 I 0 V 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 13 <br /> C�O,UNN-AGENCY <br /> CITY NAME S7oG! , STATE ZIP WJ PHONEHAPEA Cpp��o <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) y/6 <br /> NAME ?At, �� � Etec4puCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS /� y,,.-// 1 I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> I' L S�/•[i�cJ✓� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> G <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME /1 /� STATE ZIP O DE PHONE#,WITH AREA CODE <br /> [z Fi�..n-r.�.Gcs CA- y o (o <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. IL 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 NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY01, JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE <br /> 39lM9l = = lolollI= 101 O I o o <br /> CURRENT LOCAL AGENCY FA TY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> t'A Cm F <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT7MI�OYN CODE CENSUS TRACT as SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Y V( � O ! <br /> Q q �` ,`YES NO "7 /OG <br /> CNECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> RM A(3-2-88) <br /> `rDATA PROCESSING COPY 11.00, <br />