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S�A'`iviitl rhf <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A': UNDERGROUND STORAGE TANK PROGRAM �a Z <br /> �< Io <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P ENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME rJ^\/1an V CARE OF ADDRESS INFORMATION <br /> \, •� .� <br /> NEAREST CROSS STREET ✓sAmmesse 0 PARTNERSHIP 0 STATEAGDV <br /> ADDRESS [I CORPORATION 0 LOCAL-AGENCY ElFEDEW AG90 <br /> '333 E� <br /> VO+IA 5T <br /> Cl INDNIDDAI 0 CWNTf-AGENC! <br /> STATE ZIP <br /> CIN NAME CODE SITE PHONE N,WIT RE CODE <br /> STod--ram CA 95241 — -S�d <br /> TYPE OF BUSINESS 2 DISTRIBUTOR4 PROCESSOR '/Box if INDIAN EPA ID N _ N of TANKY .09 <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTRESERATION or ❑ AT THIS SITE <br /> CK <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA COD DAYS: NAME(IAST,FIRST) PHONE N WITH AREA CODE <br /> I 20 _ Zs26 sa � <br /> NIGHTS. NAME(LAS FIR ) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sai,,,Pi it <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> N Fl aibroad �o . <br /> MAILING or STREET ADDR S,3 Be.✓ to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> .�./� L\ ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> '7 <br /> C, 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME ^—rvC4&Ts-;I,l STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 6A I <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <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. ❑ I. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION S AGENCY M FACILITY ID M If of TANKS at SITE <br /> 3qf = = 101 () 0K0 6 101ao <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE <br /> UN10N83 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> DE CENSUS TRACT k SUPERVISOR-DIST IC�TTY CODE BUSINESS PLAN FILED DATE FILED <br /> �o (/0 YES NO ❑ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> ,W\ FORM A(3-2-88) <br /> `� DATA PROCESSING COPY <br />