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STATE OF CALIFORNIA-- WATER RESOURCES CONTROC4OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE -4 <br /> Cil <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C <br /> FACILITY/ IT NAME CARE OF ADDRESS INFORMATION <br /> I cote e "-k es <br /> ADDRESS NEAREST CROSS STREET ✓Bmroidkak Cl PARTNERSHIP 0 STATE AGI <br /> 0CORPORATION 0 LOCAL-AGENCY 0 FEDEWAG90 <br /> Do q 0 /-N Atw— INDmowL ❑ 10An -AGD+a <br /> CITY NAME STATE ACODE SITE PHONE N.WITH AREA CODE <br /> F-rewd.. CA Llrz 4 <br /> If TYPE OF BUSINESS: ❑p DISTRIBUTOR flOCES50fl ✓Box if INDIAN EPA ID N <br /> RESERVATION or Aof HIS SI <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE 5 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) AA7j PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> N. Thl ' � --.-77i" <br /> NIGHTS: NAME(LAST,FIRST) PjjONE#WLTH AREA&DE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �/ / <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I N e- <br /> MAILINGorSTREETADDRESS ✓ to indicate ❑ PARTNERSHIP 0 STATE AGENCY <br /> O_ INDIVIDUAL <br /> 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 13� 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> Ievcpk 170 -?9;L-^ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sam 'i <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 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. ❑ II.e 111. ❑ <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 b JURISDICTION N AGENCY M FACILITY ID It If o/TANKS at SITE <br /> ® 3 <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE IF WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DDAAT FILE J, <br /> -3,-an 3S YES [-] E:] O NO d/ <br /> CHEC • PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATIONS), UNLESS THIS IS A CHANGE OF SITE INFORMATIONON ONLY <br /> ORM A(3-2-81ir} <br /> DATA PROCESSING COPY a/ <br />