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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD rp <br /> 4 it iy '.,TyF <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•�^%" <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q 11 <br /> i0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME /a /� �/_ CARE OF ADDRESS INFORMATION <br /> s G 1`" P (fifu <br /> ADDRESS / NEAREST CROSS STREET ✓�efIooawe ❑ PARTNERSHIP ❑ STATE AGENCY <br /> W' C/u l v�(. Rai 1 I CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGEND <br /> N ❑ INDI DUAL ❑ COUNT AGENCY <br /> CITY NAME v STATE ZIP ODE SITE PHONE p,WITH AREA CODE <br /> G l CA 5a o 00,?)11-6(a-q313 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR Fj 4 PROCESSOR ✓BOX" YDIAN EPA ID p <br /> RESERVATION or �/'/yam- ,, N of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM EwiOTHER TRUST LANDS ❑ ,V v v� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Charles Foun-tai rU <br /> NIGHTS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sarni (�TOi `t(a7-1Q73y <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA31 O G'< Go I �� 6'u CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Pa X to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LWCORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY3 3 6 ❑ INDIVIDUAL 11 COUNTY AGENCY <br /> CITU NAME' STATE ZIP CODE PHONE N WITH AREA CODE <br /> S CA ao <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SC& m e S `� �Y' <br /> MAILING or STREET ADDRESS ✓Dox to indicate 1:1PARTNERSHIP 11 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <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. ❑ II. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 10101 ) 1= D 00 <br /> CURRENT LOCAL AGENCY FACILITY ID N APP ED Y NAME PHONE N WITH AREA CODE <br /> ,S oc- KO <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> // t? <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISr/TRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �' a 3 r / 6 YES NO <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Jr 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 Ata-2-88) / ('\ <br /> r\�V DATA PROCESSING COPY <br />