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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD l° <br /> , , x <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION }¢� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E#YlrcHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Fq7qj -,7 <br /> v <br /> 1 C) <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> o —r F iliGi+ -* 1 -,To e, pI i n ry <br /> ADDRESS NEAREST CROSS STREET RAr 10'r ate 0 PARTNERSHIP 0 STATE AGENCY <br /> 93511 CORPORATION Q,t�LAGENCY ElFEDERAL AGENCY <br /> 11INDIVIDUAL ❑ COUNiKA6ENCl <br /> CITY NAME STATE ZIP CODE SITE PHONE If.WITH AREA CODE w <br /> CA 9537 204 35- <br /> TYPE OF BUSINESS: ❑i DISTRIBUTOR ❑ 4 Pfl ESSOR I ✓Bax if INDIAN EPA ID a <br /> RESERVATION or N of TANK'N <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ IL)N E7 AT THIS SITE I <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 /> 09 83� 4yZ0 u g - <br /> NIGHTS: NAME(LAST,FIRST) PH E N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) NE tt WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME c CARE OF ADDRESS INFORMATION <br /> MAILING or STREET A41DRESS ✓Box to intlicate �❑� PART��ERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION IAL;l R-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME - STATE ZIP CODE PHONE k,WITH AREA CODE <br /> 1 0 A Cq 1 9s 3 7L 23!;_-5_) <br /> III. TANK OWNER I ORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S+me lk-V, <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ it. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION N AGENCY R FACILITY ID n a of TANKS at SITE <br /> E�l 10 0 T 3101310111 <br /> CURRENT�1 GCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> ' U <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> KVA- <br /> LOCATION CODE CENSUS TRACT N SUPERO POR-DISTRICT CODE BUSINESS PSN FILED NO ❑ DATE FI D <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 1 toy) <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(3-2-88) c <br /> .-r DATA PROCESSING COPY <br />