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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA": UNDERGROUND STORAGE TANK PROGRAM =m <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 S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE >� <br /> 10 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1 A/O <br /> �Y N <br /> ADDRESS NEARESTCROSS STREET ✓Bow mimrcate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL Cl FEDERAL AGENCY <br /> I LIP ❑ INOIVIWAI 0 COUMYAGENCY '1/ <br /> CITY NAME STATE ZIP CODE ITE PHONE 4,WITH AREA CODE <br /> CA QS 205 4(O c M L <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a N of TANK's <br /> ESERATION <br /> ❑ 1 GAS STATION ❑ 3 FARM �BTHER TRUSTT LANDSo ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> l.� RA>.PH E, 2oq y1�3- 2 91 <br /> NIGHTS. NAME(LAST,FIRST) PHONE ft WITH AR[A CODE I NIGHTS. NAME(LAST,FIRST) PHONE B WITH AREA CODE <br /> 5AME SAME <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME DARE OF ADDRESS INFORMATION <br /> A. M ) [rAfz, o <br /> MAILING or STREET ADDRESS141 ZL4 ✓_ Beto indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> D ZIRFIPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> Qs iC7 -- <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) a0q S/ ' `13 75 <br /> NAMECARE OF ADDRESS INFORMATION <br /> HID NE <br /> MAILING or STREET ADDRESS ✓iSox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> LY CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> q s 2oL I ?(moi 11o3-53it 2- <br /> IV. <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. v 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 /> COUNTY K JURISDICTION IF AGENCY R FACILITY ID N k of TANKS at SITE <br /> ® = = I d 01K= lnlnlo I I L <br /> CURRENT LOCAL AGENCY FACILITY ID M A ROVED BY NAME 9 PHONE A WITH AREA CODE <br /> k- C E_ D <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PEAN FILED DAE )LED�y <br /> 23-80 42 YES ❑ NO 3 n/ <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 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 /> FORM A(3-2-88) <br /> •+—� DATA PROCESSING COPY �'�+' <br />