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. ,,=-a,: -,yr; -'9`D+4`•-'• :e••�., ,yT,:V�,.tn,.:"+r.,,aY..v,T _ ,,,r.. . .. .. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 VNEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:16 TEMPORARY SITE CLOSURE Q I N <br /> 0 1 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W j <br /> O / / E Cwu7xP1 SToRc .cels UL <br /> ADDRESS NEAREST CROSS STREET <br /> ✓BmnaPAAREl STATE AGENCY <br /> ❑ LOCAIAGY C3 FEDEAAGENG <br /> YC' L( NMDUA <br /> ❑ COUSFY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4.WITH AREA CODE <br /> .Y047 4 CA 9s-572 4 - 3 <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box A INDIAN EPA ID N <br /> Ll � ❑ ❑ TRUSTKS <br /> RESERLANDS <br /> ATION a ❑ Aof HIS SI <br /> GAS STATION 3 FARM 5 OTHER AT THIS SITE 3 <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 /> ,5,v v s /rU4l 2oq-3 - ? Ld?4 LUM N - 3'sv�2 m <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> E.-v v /6— g —3 Y olo.,u — 34s-V—?/ <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> ! ARA S?G?dIQ L` Al ' <br /> MAILING or STREET ADDRESS ✓Baao - e 13 PARTNERSHIP ❑ STATE-AGENCY <br /> RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> !S . NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE N,WITH AREA CODE <br /> `1S?2o 2 -3 P-b <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G 3IAIT <br /> S E�t/wl U Ll <br /> MAILING or STREET ADDRESS ✓Box to male ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /T ❑ C TION <br /> IllLOCAL-AGENCY ElFEDERAL-AGENCY <br /> DIVIOUAL ❑ COUNTYAGENCY <br /> CIT'NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CA 20 0 -0361?- 63 <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. 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLI NTS NAME(PRINTED&SIGNATURE) DATE <br /> Aio�oCzo�> <br /> va- &9,3-Z22� <br /> LOCAL AGENCY USE ONLY /L("ny/•H <br /> �s <br /> COUNTY# JURISDICTION N AGENCY R ACI ITY IDX R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONEY WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N j� SUPERVISOR DISTRICT CODE BUSINESS PUN FILED DATE FIL�EA <br /> 2 2j, lJ 3 _0 YES NO �{I Z /tiO <br /> CHECKR PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 1 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 /> FORMA(3-2-Bel <br /> W � DATA PROCESSING COPY <br /> �/ - 3 -7v <br />