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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION1�� � <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 IV <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE d m <br /> w <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDEIESS INFORMATION <br /> �cxx.{ 10vI rj kc15 hILPI Da A Ha v <br /> ADDRESS NEAREST CROSS STREET ✓Box to Nj,,e ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ��nn p[� ❑ CORPORATION 11LOCAL AGENCY 11FEDERAL AGENCY <br /> t.atii E• w O D Cher Sfi ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> LocktiI CA 7A7 -5 2 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA 10 # <br /> 1pf1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ 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 /> kq5kmussr5i­J kltsdvinj 2,i- 7Ar7 -5 '1- Lq Wc.cY:'� N -7A -511 2_ <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGH S: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE FAOOREFORM ION <br /> c 't VISS IN QSJV4550fj <br /> MAILING of STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> O• /—J/ 11ElCORPORATION ClLOCAL-AGENCY 11FEDERAL-AGENCY <br /> •Jw INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Lak eer 95937 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> TWA t <br /> MAILING qLISTREET ADDRESgS(J/Y�(/ ✓ oxton,dicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / ' V r B ( /// ❑ INDIVIDUAL PORATION ❑ COUNTY AGENCY 11 LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> se0cme— 00- <br /> ay _ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS I wk Ix <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I-Itle it. ul Ill. ❑ <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# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> = = I I I 11613 1 1 1:31 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE IF WITH AREA CODE <br /> cl<t.i'f <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F <br /> ? <br /> 2 3.90 3.210 YES NO E] 11'I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At BY: y� <br /> C-Tl <br /> \ THIS FORM MUST OBEACCOMPANIED BY AT LEASOR MORE TANK PERMIT FORM `B'APPLICATION(S), USS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> RMA(3-2-86) <br /> DATA PROCESSING COPY <br />