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limmor <br /> STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD <br /> FORM 'A': 151 <br /> UNDERGROUND STORAGE TANK PROGRAM ="� �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT R?j CHANGE OF INFORMATION ❑ 7 PERM NTLY CL SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) G <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> CS S cher U�Fj�G ;Oxl <br /> ADDRESS NEAREST CROSS STREET ✓Bw Wndcale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> l 35 E F M Rc uKN O IN�aAAL Cl LOCALAGENCY ❑ ROFu AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA S O <br /> g07_?97 <br /> b/7 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N #of TANKY <br /> ❑ 1 GASSTATION ❑3FARM �SOTHER TRUSTMLA, So ❑ AT THIS SITE <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 /> (c 1�1crYn za1-75t8 -6/2 GK/`� <br /> NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE N WITH AREA CODE <br /> O/. E ob/N 2 0rj-�yB-fJ/2 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S 7 <br /> MAILING or STREET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sifflo ,ls-11C <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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 AO 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 R JURISDICTION R AGENCY N FACILITY ID R R of TANKS at SITE <br /> 3 q:] = = O 10 1 z 10 -7 161 10 10 10 la <br /> CURRE LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WIT"AREA CODE <br /> Esq !S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> rLOCATION CODE SUPERVISOR-DISTRI <br /> CENSUS TRACT N CT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 123- 90 <br /> L YES [:] NO I C-4 <br /> CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / <br /> FORM A(3-2-RB) <br /> �� vm/ DATA PROCESaING COPY �� <br />