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Cr- (CAUP'Cki,' 1A WATER RESOURCES COMP OL BOARD <br /> FORM "A": UNDERGROUND STORAGE TANK PROGRAM b <br /> fto <br /> L;7� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE `"It, RN" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 7 PERAAANFAITI Y CI <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> tai <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARS OF ADDRESS INFORMATION <br /> i V_01( Grnwers �J( J <br /> , , t:(ar�.► u t Q tire) <br /> ADDRESS / / NEAA/R�EST�JCROSS STREET ��o <br /> Box tovdal Cl PARTNERSHIP ❑ STATE-AGENCY <br /> Q4 eQ s4 W tD (-1 w INNDN�{DUA�IDN ❑❑ LOCAL-AGENCY AG ❑ FEDERAL-AGENCY <br /> ENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> 54oc.k+e N CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSORTR <br /> ✓Box if INDIAN EPA ID # <br /> ❑ ❑ RUSTVLANDS TION or ❑ 8 of HIS SITANK'TE �y <br /> 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE ('`�/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EPAERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CAR OF ADDRESS INFORMATION <br /> i of �^dGwe( I,�Gt 4,v Gfi cX No <br /> MAILING or STREET AD ESS ✓ oz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> rr�, <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O {l- 12 / INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> c Cw 1175353 120?-52-6-WeV <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL Q COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Id. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH AGOtlC ADDR30Z SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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# JURISDICTION# AGENCY N FACILITY IDN N of TANKS at SITE <br /> 3q oaz- oev � p0 <br /> CURD!NT LOCAL AGENCY FACILITY IDM APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> V� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUUGER <br /> LOCATION CODE CENSUS TTRRAACT# SUPERVISOR-DISTRICTCODE BUSINESS PLAN FILED DATE FILED <br /> ® Z3. O V �f —/ YES ❑ NO ❑ 1 3 S9 C <br /> CHECK M pERYIT AL70U4T SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORD MUST BE ACCOVPANIED BY AT LEAST�1)OR LORE TANG(PERLIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONy <br /> J <br /> FORM A(3-2-88) <br /> _ DATA PROCESSING COPY L- <br />