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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAMa <br /> S11FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> c <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 01 Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 <br /> FAACILITYISITE NAME CARE OFADDRESS INFORMATION <br /> Gonot ire <br /> -Y" <br /> ADDRESS _ NE EST CPp5$CTREE7 ✓9R v:0 ❑ LOCAL AGENCY <br /> ❑ STATE-AGENCY <br /> 00 <br /> 0coIPawLaN ❑ COUN AGENCY ❑ FBXPu acENLY 00 <br /> 1 ❑ INDIVIDUAL ❑ WUNTlAGENC/ (y) <br /> -CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE KZ+ <br /> CA a :L D�/ <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 P OCESSOR ✓Box if INDIAN EPA ID p ##I TANICN <br /> RESERVATION or <br /> ❑ t GAS STATION ❑3 FARM OTHEfl TRUSTLANDS ❑ /W FSC. AT THIS SITE O <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 /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 1.:J0� -/ Cu ire F/2 u,b,beI- CARE OF ADDRESS INFORMATION <br /> lJ (� � <br /> MAILING or STREET ADDRESS ✓o.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CD_/ I LFlCORPORATION ElLOCAL-AGENCY 13 FEDERAL-AGENCY <br /> Jr 11 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP ODE PHONENITHARJ(✓EA CODE <br /> QH .W <br /> ,3/ w <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME �-IQ J... � DaJnCARE OF ADDRESS INFORMATION <br /> -Sar <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 5A%IE STATE ZIP CODE PHONE p,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: L 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 N of TANKS at SITE <br /> ,39 = = © oao7 OQD <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> moo v <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENS''U11S TRACTT* SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DAATE FILED p� <br /> © OE 3 , U O YES [—] NO ❑ 0 pZ �/ <br /> CNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT B <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 /> FORMA(3-288) <br /> s DATA PROCESSING COPY <br /> i <br />