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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A <br /> S. <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT EK5 CHANGE OF INFORMATION ❑ 7 PER NTLY CLOSED SITE ~ <br /> N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NA _ CARE OF ADDRESS INFORMATION <br /> tG N L <br /> ADDRESS NEAREST CROSS STREET bbGkak 0 PWD &PNIP 0 STATEAGDCY <br /> fAPPOMTION 0 LOGL.AGENLY 0 ROBUL-AGENLY i <br /> INOMOLK 0 WUNW-AGENC/ ' <br /> CITY NAME ''/ STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S-0i-to r`I CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID# <br /> RESE❑ of TANK's <br /> 1 GAS STATION ❑3FARM ❑50THER TRUSTYLANDS or ❑ AT THIS SITE [;— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE <br /> A �aR � - :. tq-t - A l oe, 20 — Z z� <br /> NIGHTSNAME(LAST,FIRST)f J PHONE#WITH AREA CODE NIGHTS: NAM T,FIRS, PHONE#WITH AREA CODE <br /> Some '3�V e <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS xito indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> GORPCRATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#.WITH AREA CODE I <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME � ��� CAPE OF ADDRESS INFORMATION i <br /> N <br /> MAILING o,STREET ADDoz to indicate 0 PARTNERSHIP 0 STATE-AGENCY I <br /> ' rr Q� CORPORATION OLOCAL-AGENCY OFEDERAL-AGENCY <br /> VV \V/((JJ 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME 5704670 STATS - ZIP C Q� / PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS L!/IrIN 95 <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> MI = = I Ll o 9 ® o <br /> CURRENT LOCAL AGENC FACILITY _* A APPROVED BYNAME PHONE N WITH AREA CODE <br /> 1�K J( W <br /> PERMIT NUMBER PERMIT APPROVAL DATE „_/ PERMIT EKP TION DATE <br /> JZ ,2D (jJ/(O/ <br /> L <br /> DE CENSUS TRACH SUPERVISO(DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 7vv uYES � NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 A(3-2-88) <br /> +� DATA PROCESSING COPY , low J <br />