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STATE OF CALIFORNIA <br /> FORM 'A': WATER RESOURCES CONTROL BOARD <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICAT . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE o I q <br /> SC) <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT <br /> ONE ITEM ❑ 5 CHANGEOFINFORMATION 7 PERMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT ❑4 AMENDED PERMIT64 <br /> ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) (v <br /> FACILITY/SITE NAME r <br /> CI CARE OF AD DRESS INFORMATION / f�7 <br /> AD SS at'(C Wt 1( /tuck ct tl , /Na to 6&-kktt' <br /> NEAREST CROSS STREET ✓B win6ale ❑ VgPMEI&HIP ❑ yTg1E.,1GENCy <br /> ns _ <br /> CITY NAME 4� d N Cl Irlomm O LcaRn gcErla ❑ ImPxu-gcFncY <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> ` CA ?5-3176 -Szs-/65O <br /> TYPE OF BUSINE 2 DISTRIBUTOR I❑�4 PROCESSOR ✓Box it INDIAN EPA ID . <br /> ❑ 1GAS STATION ❑3FARM L�G0.OTHER ESETRUSTYANDS ATION or ❑ &KN AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> OAVS. NAME(LAST,FIRST) PHONE N WITH AREA CODEDAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> rf <br /> G(y r, I,e (62S —/6SQ (,keN <br /> NIGHTS. NAME(LAST,FIRST) V PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Qk IJ N <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ' CARE OF ADDRESS INFORMATION <br /> C o Ckuck s ua <br /> MAILING or 1TREET ADDRESS ✓Box to indicate PARTNERSHIP Cl STATEAGENCY <br /> J�'K. 11 CORPORATION LOCAL-AGENCY ElFEDERAL-AGENCYST7N ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#,WITH AREA CODE <br /> 3 6 Z® - 536-mYo <br /> Ill. TANK OWN6 INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e o; -g-mg, <br /> MAILING or§lfREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> c^ /�� ❑ CORPORATION ClLOCAL-AGENCY 11FEDERAL-AGENCY3� J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAe4 21P COD �OEp17376 =1 36A <br /> ,I <br /> I ( E <br /> IV. LEGAL NOTCATION AND BILLING ADDRESS S O <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ❑ 111.66 <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 R JURISDICTION R AGENCY R FACILITY ID a Mol TANKS at SITE <br /> O O O <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE <br /> nuc 0 0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> OCATION CCODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 23. <br /> \�CK X J PERMIT AM SURCHARGE AMOUNT FEE CODE YES NO <br /> ❑ C BY:/1 7 <br /> 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 /> '� \ iii DATA PROCESSING COPY �/ <br />