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STATE OF CALIFORA WATER RESOURCES CONTRIPB A <br /> FORM 'A': ORD <br /> UNDERGROUND STORAGE TANK PROGRAM V <br /> z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r . <br /> E COMPLETE THIS FORM FOR EACH FACILITY/SITE _ <br /> Cy 41Fp RNP <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT OHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE N. ME <br /> � / - <br /> a I f _ 131° *t E Y y DARE OF ADDRESS INFORMATION <br /> ADDRESS ,�L..Q /� NEAREST CROSS STREET ✓ IomduW ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> I �' `�"' s�r e t�' CORPORATION ❑ LOCAL-AGENCY Q FEDERAL-AGENCY '4 <br /> ❑ INDIVIDUAL ❑ COIJNTY-AGENCY 00 <br /> CITY NAME STATE ZIP CODES TE PHONE 4,WITH AREA CODE V <br /> Ca 5 S GO 7`7 - 3do <br /> TYPE OF BUSINESS: E 2 DISTRIBUTOR 4 PROCESSOR ✓Box if IN EPA ID # <br /> 1 GAS STATION � 3 FARM ��OTHER TRUSTESEVLANDS or j I AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> rmr bra � qI 8a3— ? <br /> NIGHTS: N (LTs_h4 <br /> PHONE#WI H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> K Yyl e_ <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION <br /> cc v 13 <br /> MAILING or STREET ADDRESS ✓Etox to indicate ❑ PARTNERSHIP El STATE-AGENCY <br /> /} rn ❑ CORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> v _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> Cl NAM STATE ZIP CODE p� PHONE#,WITH AREA CODE <br /> 2 Y-5 <br /> III. TANK OWNER INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> NAMPO C—f if'c ,:�'++�,,/6 � �r (Fre5nzr"ztkqACARE CF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LLU El 1:3 <br /> Q LOCAL-AGENCY C� FEDERAL-AGENCY <br /> ��,777 Q INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. II. III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BFST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY 1D# #of JrANK <br /> CURRENT LOC73ea' <br /> ENCY FACILITY ID/# APPROVED BY NAME PHONE# <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TFIAC�# SUPERVI QI33 T CODE BUSINESS PLAN FILED DATEp(()(��~ YES NOCHECKPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <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 /> FORM A(3-2-88) <br /> 0 DATA PROCESSING COPY <br />