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STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } m <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ely PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) Chi <br /> Cm <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> Ellis Car Wash 00 <br /> ADDRESS NEAREST CROSS STREET ✓8mi,twm 0 PARTNRE111P 0 STATE AGENCY <br /> 820 S O . Cherokee Lodi Ave WAL C0NPORATIGN Cl LoeN AGEN Y 0 FEDERAL AGENCY <br /> INGM ❑ CUM AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> Lodi CA 95240 209-333-1334 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓So.if INDIAN EPA ID N <br /> 0 RESEI GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTVLANDS or Mol TAMP# <br /> ❑ CAC000531056 ATTNIssITE 4 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> Ellis , Lance 209-333-1334 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE <br /> Ellis , Lance 209-333-1334 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Lance Ellis <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 820 S o . Cherokee ❑ CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ® INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> Lodi CA 95240 209-333-1334 <br /> Ill. TANK OWNER INFORMATION 8 ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Lance Ellis <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 820 S o . Cherokee CORPORATION 11LOCAL-AGENCY ClFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> Lodi CA 95240 209-333-1334 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. X❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER P NALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS.TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) A / DATE <br /> Lance Ellis HGfQ, 10-30-90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY M FACILITY IDM M of TANKS at SITE <br /> CURRENT LOCAL AGENCY FAGILI7Y IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODELENS�ISSTYTRACT IF �� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED/� n <br /> D� d3, ,R J YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.\ o <br /> FORM A(3-2-88) J <br /> 1 _�� 4(� ►� DATA PROCESSING COPY \ I <br />