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0T. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '""` <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m I o <br /> Ll <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION IZQMLANENTLY ED SITE I"a' <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 97O <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 50 —4 <br /> FACILICA OFDDRESINFORMATIONY1VV44e) � <br /> Alztrl, IS <br /> ADDRES2 D(ANCP NEAREST GROSS STREET Butmon? <br /> � <br /> PARTNERSHIP STATE I <br /> • IF TO 11 ��IP ❑ ROEAGS <br /> STV ❑ DNIDUPI <br /> ❑ COUNTY AGENCf <br /> CITY NAME x (� STAT7jP.pI SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p 7 K/1 <br /> r Mol TANK'e <br /> RESERVATION or /A/ <br /> &gyriAS STATION ❑ 3 FARM a OTHER TRUST LANDS ❑ (1/" AT THIS SITE/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS: NAME(LAST,FIRST) HONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> pi- {Qic�ir 2 -587-3`/ o <br /> NI TS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ID�� 1N1 _99 - S <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME^ /0 A5 AWL-: <br /> r CARE OF ADDRESS INFORMATION <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 /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME /x /� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (3 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.MI-11. ❑ If. ❑ <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 M JURISDICTION B AGENCY R FACILITY ID a W of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDA, APPROVED BY NAME PHONE N WITH AREA CODE <br /> 0221 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ON DE CENSUS TRACI#�� SUPERVISS R-DIS ICT CODE BUSINESS PUN FILED DATE F LED 12- - y S((/VJ YES NO <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT B <br /> Is <br /> (Y THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> `FORMA(3-2-88) <br /> W' �1 DATA PROCESSING COPY � <br />