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STATE OF CALIFORNIA WATER RESOURCES CONTROLBOARD <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 ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMITA�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Q <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q, <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A'RGo krNimi PAA mIN( ML D,CLv-eT <br /> ADDRESS ww tt NEAREST CROSS STREET ✓Boxta vtlicas ❑ PARfNSSHIP C STATE AGENCY <br /> 22/5 5. GktE RcJ t�EE LPI ❑ CORPORATION ❑ LOCA AGENCY ❑ FEOER IAGEN <br /> Cif <br /> IND <br /> C CORPORAIDLIAL C LOCAL AGEENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> LODT CA `1524o 20q- 368-7663 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA NO <br /> n �/l 1� p #of TANK'N <br /> I GAS STATION ❑ 3 FARM El5OTHER TRUSTTYANDSo ❑ L-ItL O V v AT THIS SITE <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 /> HIUP61J6V_hfJD , AUID 'lD9-36$-7$6'3 IltMF_Nv)RDUMEIJTALEA)62- 415- 51-2400 <br /> NIGHTS'. NAME(AST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AfLGGD PR-ODUGTS Co. <br /> MAILING or STREET ADDRESS 1 ENCY <br /> M CORPORATION ❑Y/flox to indicate 1:1 LOCAL-AGENCY C FEDERALARTNERSHIP EI `-AGENCY <br /> 2000 � XKC_pR At IQ5 PULS C INDIVIDUAL C COUNW-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 5w PI/ 4ii GA 9�F o3 (5- 57(-2 ao <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ii PPOPUC13 CO, <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY <br /> [IY CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY2U4ME000 A )A e las PU(_64A5 C INDIVIDUAL C COUNW-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 5-w M4TCo G)k 24403 15- 571- 2400 <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. ❑ I. If. ❑ <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 /> w1LuAAA S MARS W t N <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCYIN FACILITY ID If If of TANKS at SITE <br /> [3]E = = l 3 3 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> NU PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE i LED <br /> ' Vy OZ Z YES NO 5 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN <br /> U` <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(if OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-811) <br /> ✓ DATA PROCESSING COPY Y <br />