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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> 2 INTERIM PEflMIT q pMENOED PERMIT ❑ fi TEMPORARY SITE CLOSURE •O <br /> Jr� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w <br /> w <br /> ADDRESS <br /> w <br /> NEAREST CROSS STREET ✓gp.6.tlole ❑ HATNERM ❑ STATE AGENCY cm <br /> c1n NAME <br /> /Y GJ, �� s ❑ No laN ❑❑ m� GENCYX ❑ FEDERAL AGENCY <br /> STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> CA ar�J 9YFf 95 y�' <br /> TYPE S' ❑2 oil: UIOfl ❑ 1 SSOR�R'ESERVATION <br /> EPA ID a <br /> .SASSfATXkI ❑3 FARM - SOT R 10l TANK'a <br /> 04,-c7co J3 3yo?�- AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRSTT) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> t {u! -.�'--�?c'y G[ � •J17y ,9Y�-`I'� iPc7�✓C �/ f rF00 - 3-.SSs <br /> NIGHTS NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME ILAST.FIRST) PHONE N WITH AREA CODE <br /> sJs9 � /c/ -1/rot-9j v <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> Gl,° sf <br /> MAILW(Ia STflEEf ADDRESS _...e ✓ala indcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ` Or« CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE a,WITH AREA CODE <br /> 11p 4 zJO_ 3 - - <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAU-ING a STREET ADDRESS ✓BpaOfnElCale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> L 7 f - ❑ <br /> INDIVICORPODUAL EI <br /> EIOUNTY AGENCY ❑ FEDERAL AGENCY <br /> CITY NAME El LOCAL-AGENCY <br /> STATE ZIP CODE PHONE A.WITH AREA CODE <br /> C bKS <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. �Dui <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 P JURISDICTION X AGENCY Y FACILITY ID M M of TANKS BI SITE <br /> a] 0 ,2 3 e2 ? 1 <br /> CURRENT LOCAL AGENCY FACILITY 101 OVED BY NAME PHONE 1 WITH AREA CODE <br /> L,1 14 � <br /> PERYIYWUYSEII PERMIT APPROVAL DAT . PERMIT EXPIRATION DATE <br /> LOCATIONNP C�ODE. CENSUS TRACT 1 SUPESVUOR•DISTRICT CODE BUSINESS PLAN FILED DATE I'll c <br /> YES NO � <br /> CHECK/ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY^l' <br /> W' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OF E TANK PERMIT FORM 'B'APPLICATION(S), UNLESS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2.86) <br /> DATA PROCESSING COPY <br />